1

THE EXPERIENCES OF REGISTERED NURSES CARING FOR PEOPLE WITH
SUBSTANCE USE DISORDERS IN EMERGENCY DEPARTMENT SETTINGS
by
Gwen Keeler
B.A., University of Victoria, 2002
BScN, British Columbia Institute of Technology, 2006

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIERMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
December 2017
© Gwen Keeler, 2017

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ABSTRACT

Substance use is a phenomenon affecting over 250 million people worldwide, with
approximately 27 million people identified as living with a substance use disorder (SUD).
This research study addressed the question “what are registered nurses’ experiences caring
for people with SUD in Emergency Department settings?” A qualitative descriptive
methodology was used in the investigation which consisted of semi-structured interviews
with 13 Registered Nurses recruited from three Emergency Departments within northern
British Columba. Data was analyzed thematically and three major themes emerged: People
with SUD in the Emergency Department; Organizational Barriers to Care and; Beliefs and
Attitudes. This research provides insights into the challenges that nurses face caring for
people with SUD in the Emergency Department setting, the need for education and resources
aimed at improving outcomes for people with SUD, and the varying attitudes and beliefs that
nurses hold regarding SUDs and people with SUDs, and how these impact care provision.

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Table of Contents
List of Tables ............................................................................................................................. vii
List of Figures ........................................................................................................................... viii
Glossary...................................................................................................................................... ix
Acknowledgment and Dedication .................................................................................................. x
Chapter 1: Introduction and Background ........................................................................................1
Background ..............................................................................................................................2
Language and Stigma ............................................................................................................3
Definition of Substance Use and Substance Use Disorder ........................................................5
Diagnosis. .........................................................................................................................6
Incidence of Substance Use Disorders ....................................................................................7
Global incidence. ...............................................................................................................7
National and provincial incidence. ......................................................................................9
Incidence in northern BC.................................................................................................. 11
SUD and the Social Determinants of Health .......................................................................... 13
Social Impact of Substance Use............................................................................................ 14
Access to Care .................................................................................................................... 16
Role of ED and ED Nursing ................................................................................................. 18
Role of the ED................................................................................................................. 18
ED nursing. ..................................................................................................................... 18
Context and Purpose............................................................................................................ 19
Chapter 2: Literature Review ....................................................................................................... 21
Review Methods ..................................................................................................................... 21
Stage One: Development of the Search Strategy .................................................................... 22
Electronic databases and search terms. .............................................................................. 22
Stage Two: Preliminary Review of the Literature .................................................................. 23
Stage Three: Focused Review of the Literature...................................................................... 24
Stage Four: Analysis and Reporting...................................................................................... 24
Literature Review Findings...................................................................................................... 25
Personal Attitudes and Beliefs about SUD ............................................................................ 25
Emergency Department context. ....................................................................................... 25

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Canadian context and RN specific context. ........................................................................ 29
Pain management in SUD................................................................................................. 32
Literature reviews. ........................................................................................................... 35
Multidisciplinary studies. ................................................................................................. 37
Summary. ....................................................................................................................... 42
Interpersonal Relationships .................................................................................................. 44
Summary. ....................................................................................................................... 52
Organizational Factors ......................................................................................................... 52
Summary. ....................................................................................................................... 58
Overall Summary ................................................................................................................ 58
Chapter Three: Methods .............................................................................................................. 60
Study Design .......................................................................................................................... 60
Selecting a Methodology for Qualitative Inquiry ................................................................... 61
Philosophical Foundations ....................................................................................................... 63
Ontology and Epistemology ................................................................................................. 63
Ontology. ........................................................................................................................ 64
Epistemology. ................................................................................................................. 64
Situation of Self. ................................................................................................................. 65
Role as RN. ..................................................................................................................... 65
Role as an educator. ......................................................................................................... 67
Method................................................................................................................................... 68
Sample ............................................................................................................................... 70
Recruitment..................................................................................................................... 70
Inclusion criteria. ......................................................................................................... 71
Exclusion criteria. ........................................................................................................ 71
Data Collection and Analysis ............................................................................................... 73
Data Collection................................................................................................................ 73
Data Analysis. ................................................................................................................. 75
Ethical Considerations ......................................................................................................... 77
Trustworthiness................................................................................................................... 78
Chapter Four: Findings ............................................................................................................... 81
Theme One: PWSUD in the ED ............................................................................................... 81

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Beliefs about the Role of the ED and the ED RN ................................................................... 83
Challenges of Providing Care. .......................................................................................... 85
Wanting to do the Right Thing. ............................................................................................ 88
Theme Two: Organizational Barriers to Care ............................................................................ 92
Preparedness ....................................................................................................................... 92
Formal and informal preparation. ...................................................................................... 93
Barriers to education. ....................................................................................................... 98
Knowledge deficits and consequences. .............................................................................. 99
Resources and Supports ..................................................................................................... 102
Theme Three: Beliefs and Attitudes ....................................................................................... 110
Personal Beliefs and Attitudes ............................................................................................ 110
Patient and Provider Interface ............................................................................................ 116
Interpersonal Interactions. .............................................................................................. 116
Summary .............................................................................................................................. 122
Chapter Five: Discussion........................................................................................................... 123
Nurses’ Experiences of Caring for PWSUD in the ED ............................................................. 123
PWSUD in the ED ............................................................................................................ 124
Wanting to Do the Right Thing .......................................................................................... 126
Organizational Barriers to Care .............................................................................................. 128
Preparedness ..................................................................................................................... 128
Resources and Supports ..................................................................................................... 131
Beliefs and Attitudes ............................................................................................................. 134
Patient Provider Interface................................................................................................... 136
Stigma. ......................................................................................................................... 136
Recommendations for Education, Policy and Practice, and Research ........................................ 139
Education ......................................................................................................................... 140
Policy and Practice ............................................................................................................ 140
Research ........................................................................................................................... 142
Strengths and Limitations ...................................................................................................... 143
Conclusion ........................................................................................................................... 145
References ............................................................................................................................... 147

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Appendix A.............................................................................................................................. 162
Appendix B .............................................................................................................................. 165
Appendix C .............................................................................................................................. 166
Appendix D.............................................................................................................................. 175
Appendix E .............................................................................................................................. 177
Appendix F .............................................................................................................................. 178

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List of Tables
Table 1: Participant Demographic Information…………………………………………81

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List of Figures
Figure 1: Progression of Analysis…………………………………………………………...76
Figure 2: Summary of Themes………………………………………………………………82

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Glossary
Compassion
Satisfaction

Describes all the positive feelings that people derive from the act
of assisting others. This can be linked to a caregivers’ experience
of job satisfaction (Sacco, Ciurzynski, Harvey, & Ingersoll, 2015).

Critical Care

It is defined as the specialized care of clients with life threatening
conditions. These clients require comprehensive care and constant
monitoring. This kind of care usually takes place in an Emergency
Department or an Intensive Care Unit depending on their needs
(Critical Care Services Ontario, 2015).

Dual Diagnosis

A term used to describe people with severe mental illness and
concurrent substance use disorder (Anderson, 2004).

Person First Language

Emphasis is placed on the person rather than the issue thus making
sure that the diagnosis is not the defining attribute of the person
suffering (Jensen, et al., 2013).

Role Adequacy

Having and having confidence in the knowledge required to carry
out a role. (Loughran, Hohman, & Finnegan, 2008).

Role Legitimacy

Comfort in the knowledge that the role you hold has the right to
address particular client needs (Loughran, Hohman, & Finnegan,
2008).

Street Involved

This term refers to varying degrees of homelessness including
living outside or in unsafe, inadequate or insecure housing
(Pediatric Child Health, 2013).

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Acknowledgment and Dedication
This journey has been a long one for my family in particular. They have been
unfailingly supportive and I could never have done this without them. I wish to acknowledge
their participation and sacrifices individually. My husband, Norman, has been a constant
driving force for me; always pushing me to do more and encouraging me to meet my goals,
while at the same time picking up the slack at home. In the moment, I was not always
gracious, but I do know that without his love, support, and that push now and again, I might
never made it. My children, Liam, Fiona and Nora, have been patient and forgiving of the
sacrifices they have made in not having me at home much over the last year, and I promise
them I will make up for it in spades over the next year. Finally, my parents, John and Meryl,
mom and dad, they have looked after my children, fed me, listened to me complain, and
supported me throughout this process. I will be forever grateful to them all and I dedicate this
work to them.
I would also like to acknowledge my supervisory team Dr. Davina Banner-Lukaris,
Linda Van Pelt, and Dr. Linda O’Neill for the assistance they provided in creating this
document. Further, I have had a multitude of support from my co-workers and friends
throughout this process and they deserve an acknowledgment here as well. This really was an
endeavor that was made possible by my village.

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Chapter 1: Introduction and Background
Substance use is a global phenomenon that is characterized by the precarious use of
psychoactive substances, including alcohol or drugs (World Health Organization (WHO),
2015). It is estimated that over 250 million people worldwide have used substances, with
approximately 27 million of those identified as living with a substance use disorder (SUD)
(United Nations (UN) Office of Drugs and Crime (2015). SUDs are costly to the individual
and society at large, and are linked with wider social impacts including increases in
communicable diseases such as Human Immunodeficiency Virus (HIV), drug-related crime,
and health care costs associated with hospitalization for substance related health issues
(Public Health Agency of Canada, 2013). Thus, SUDs impact not only the individuals who
suffer from SUD, but also the communities in which they live (Rhodes et al., 2006).
Mental health and addictions (MH&A)-specific health care services are designed to
assist people with SUD (PWSUD) to manage their conditions. However, MH&A services in
British Columbia (BC) are limited, particularly in rural and small urban settings such as those
communities located within the Northern Health Authority (NHA) region (Bellringer, 2016).
The disparity of services in these regions, coupled with current drug policy, which makes the
procurement and use of certain controlled substances illegal, results in PWSUD experiencing
difficulty accessing health care and social services related to stigma and fear of legal
consequences (Bellringer, 2016; British Columbia Ministry of Health, 2009; Browne, 2010;
Controlled Drugs and Substances Act, 1996; Fischer, 1995; Ford, 2010). For those with
limited access to health care, emergency departments (EDs) are often a first point of entry
into health care. Within these settings, patients are cared for by an interdisciplinary team

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including physicians, respiratory therapists, social workers and nurses. However, little is
known about the experiences of health care providers delivering care to this population.
This qualitative descriptive study responded to this gap in knowledge by exploring
Registered Nurses’ (RNs’) experiences of caring for PWSUD in ED settings. This research
took place in three EDs located in the NHA. It uncovered the insights of frontline ED nurses
and highlighted the challenges and opportunities that exist when caring for PWSUD. Gaining
insight into the experiences of RNs within the ED is crucial and will provide vital data to
support the development of effective health care services to improve patient care and
enhance the experience of providing care for RNs within the ED. This study was guided by
the question: What are the experiences of Registered Nurses caring for people with substance
use disorders in an emergency department setting? The following sections will explore
SUDs in more detail and will provide a background to the research.
Background
Substance use is a costly and resource-intensive phenomenon that is associated with
not only individual impacts but also larger social impacts such as increased cost within the
health care system, greater cost within the judicial system and social costs at both the
individual and community level (Public Health Agency of Canada, 2013; Rhodes et al., 2006;
WHO, 2015). While the rate of SUDs worldwide has remained more or less constant, the
incidence is increasing over time and more individuals are negatively impacted due to the
ever increasing world population (UN Office of Drugs and Crime (2015). In northern British
Columbia, access to specialized care for PWSUD is limited geographically and thus PWSUD
must sometimes utilize ED services to meet their health needs. A recent study stated that in
the United States, up to 4% of all ED visits could be attributed directly to SUD and that 33%

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of ED clients have SUD as either a primary or secondary diagnosis (Cooke, 2017). The
purpose of this research was to examine ED nurses’ experiences of caring for PWSUD. In
order to contextualize the research, I will present an overview of the definitions and impacts
of SUD and provide a description of the ED and ED nursing. However, I will first begin with
an introductory discussion of the language used in this research because great lengths were
taken to use language that did not reinforce the stigma already associated with substance use
and SUD.
Language and Stigma
SUD has been widely studied from many perspectives including, but not limited to,
the biophysical study of SUD, the societal impacts of SUD, and the attitudes and beliefs held
by health care professionals about SUD and PWSUD (Benyamina et al., 2010; Broyles et al.,
2014; Buxton, Tu, & Stockwell, 2009; Ford, 2010; Orna, Yuferov, & Kreek, 2012; Smith,
2012; UN Office of Drugs and Crime, 2015; van der Woerd, Cox, Reading, & Kmetic, 2010;
Wakeman, 2017; Xuei et al., 2008; Zhao, Vallance, Martin, Macdonald, & Stockwell, 2012).
However, substance use is a highly controversial and stigmatized topic; when stigma is not
addressed directly it can have detrimental effects on the stigmatized group. Language exerts a
powerful influence over the way societies think about their environments and how
individuals think about themselves (Broyles et al., 2014). If not carefully considered,
language can have a negative impact on societal perspectives surrounding substance use and
the potential for treatment and recovery from substance use (Broyles et al., 2014). With that
in mind, the labels necessary to explore RNs’ experiences of caring for PWSUDs have been
carefully chosen; a person first approach to language has been identified as the most

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appropriate and least stigmatizing descriptor (Wakeman, 2017). The aim is to use language
that is free of judgment and that does not perpetuate existing negative stereotypes.
A variety of terms have been used to describe SUD in the literature. These include,
but are not limited to: substance abuse, substance misuse, drug abuse, illicit drug/substance
abuse, and problem drug/substance use. Recent changes in medical diagnostic language have
occurred in the Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition
(DSM-5) to address stigmatizing labeling. However, the changes have not yet been
incorporated throughout the health care system in BC and beyond. In the interest of
supporting de-stigmatization of substance use, the person first approach will be taken in
identifying those with substance use disorders with the phrase people with substance use
disorders in this study. This phrase discourages the use of labels, such as addict or user, that
denote the person as the problem and encourages respect and dignity for the individual as
more than the disorder they live with (Jensen et al., 2013). People with substance use
disorders is a less value laden term and also highlights the medical/psychiatric nature of the
illness (Broyles et al., 2014). It is important to note that although addiction is still an
accepted diagnostic term that is used in public institutions and programs, there are significant
implications of its use including perpetuation of stigma and potentially deterring PWSUD
from accessing those services (Jensen et al., 2013).
Furthermore, there will be no distinction made between dependency and abuse.
Rather, SUD will be considered a continuum which encompasses any substance use that has
negative health and social outcomes (Health Officers Council of British Columbia, 2005).
The word recovery will be used to describe the processes used by PWSUD to improve health,

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quality of life, direct their own health care experiences, and to strive for wellness however
that is defined by the individual (Jensen et al., 2013).
While every effort has been made to use person first language, the language choices
of the participants in this qualitative research study have not been changed in order to both
preserve the authenticity and credibility of the research process and to further highlight the
real world attitudes, opinions and perspectives of RNs caring for PWSUDs.
Definition of Substance Use and Substance Use Disorder
The World Health Organization (WHO) (2015) defines SUD as “the harmful or
hazardous use of psychoactive substances including alcohol and illicit drugs” (para. 1). In
contrast, the Public Health Agency of Canada (2013) defines substance use simply as
medicinal or non-medicinal use and specifies that it may be legal or illegal use. This is
congruent with the American Psychiatric Association’s definition of SUD (American
Psychiatric Association, 2013). The DSM-5 no longer differentiates between abuse and
dependence but rather defines SUDs as mild, moderate or severe and bases the diagnosis on
several factors including control, social impairment, high risk use, and pharmacological
criteria specific to individual drugs, including alcohol (American Psychiatric Association,
2013). Once an SUD is established, there is a well-recognized set of behaviours that PWSUD
begin to exhibit including “a strong desire to take the [substance], difficulties in controlling
its use, persisting in the use despite harmful consequences, a higher priority given to
[substance] use than other activities and obligations, increased tolerance and sometimes a
physical withdrawal state” (WHO, 2015, para. 1).
SUDs have been the topic of much controversy for decades. The American Society of
Addiction Medicine has defined SUD as a “primary and chronic disease” (Smith, 2012, p.1).

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It is presented as a two-pronged health issue related in part to the genetic makeup of an
individual in conjunction with a set of physiological changes and some compulsive
behaviours that occur with the use of psychoactive substances (Smith, 2012). Psychoactive
drugs include prescription substances such as opioids and benzodiazepines, as well as
controlled substances such as alcohol, marijuana, cocaine, methamphetamines, and heroin
(American Psychiatric Association, 2013; Benyamina, Kebir, Blecha, Reynaud & Krebs,
2010; Health Officers Council of British Columbia, 2005). Smith (2012) suggests that SUDs
result from an excess of dopamine in the midbrain that leads to damage to brain circuitry
associated with the reward system, as well as systems associated with motivation, judgment,
and memory. This disease process can be responsible for a wide range of physical,
psychosocial, and spiritual expressions (Health Officers Council of British Columbia, 2005;
Smith, 2012). While associations have been made concerning the determinants of health and
substance use, there is also likely a genetic factor that plays a small role in increasing the risk
for SUD (Benyamina et al., 2010; Orna, Yuferov & Kreek, 2012; Xuei et al., 2008).
Diagnosis. A diagnosis of SUD is made based on the presence of various
physiological manifestations and a cluster of behavioural characteristics that occur within a
specific period of time, usually a twelve-month period (American Psychiatric Association,
2013). The physiological characteristics include increased tolerance to the substance or
diminished effect with consistent dose of the substance, withdrawal symptoms related to
disuse of the substance, and the inability to stop taking the substance (West & Miller, 2011).
A table of commonly used substances, their short and long term impacts as well as
withdrawal symptoms, has been included in Appendix A. In addition to the physiological
characteristics, the behavioural characteristics of SUD include: increased time devoted to

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activities related to getting, using or recovering from use of the substance; negative impacts
on social life, work life or recreational activities; continued use regardless of knowledge of
the negative physical and psychological problems associated with use of the controlled
substance (American Psychiatric Association, 2013; West & Miller, 2011).
An important aspect in diagnosing SUD is that the PWSUD must be aware of the
nature of their substance use, and they must have tried to or expressed a desire to cease
substance use (American Psychiatric Association, 2013; West & Miller, 2011). Management
strategies for SUD can vary widely but generally appeal to one of two schools of thought:
abstinence based approaches or harm reduction based approaches (Ford, 2010). The
abstinence based approach embodies survivorship and heroism. This approach focuses on
cessation of drug use and the prevention of relapse into continued substance use (van der
Woerd, et al., 2010). Conversely, harm reduction programs focus on reducing the harms
associated with substance use. Within this philosophy, there is no expectation of cessation of
use but rather, a focus on safer practices related to substance use (Ford, 2010; van der Woerd
et al., 2010).
Incidence of Substance Use Disorders
Global incidence. Although substance use is a global issue, estimating the precise
rate of substance use is extremely difficult since many countries do not collect data or,
among those that do, the number of people experiencing SUD is frequently underreported
(Buxton, Tu & Stockwell, 2009; UN Office of Drugs and Crime, 2015). A key factor in this
underrepresentation is the type of data collection methods that are typically used such as
household surveys, which rely on self-reports of substance use. Furthermore, such
approaches do not capture information from certain marginalized populations such as people

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who live on or near the street (Buxton, Tu, & Stockwell, 2009). Likewise, the social stigma
and potential legal consequences likely deter others from reporting controlled substance use.
Most often, estimates of the rates of substance use are made using survey data along with
more complex and indirect methods of measurement such as morbidity and mortality
associated with substance use and the use of recovery programs (UN Office of Drugs and
Crime, 2015; van der Woerd et al., 2010). Consequently, the true prevalence of substance use
remains unknown.
The United Nations (UN) Office of Drugs and Crime (2015) has collated all available
information from across the globe to estimate the worldwide incidence of substance use. As
previously stated, the estimate is that up to 27 million people worldwide are living with SUD.
The substances of interest to the UN Office of Drugs and Crime were opiates, cannabis,
cocaine, amphetamine-type stimulants, and new psychoactive substances (2015). Those
identifying as living with SUD account for 5.2% of the population. Due to the lack of
evidence from many countries, this is a conservative estimate. The UN ranks frequency of
lifetime substance use in order of prevalence and, with the exception of alcohol, cannabis as
the most used substance followed by opioids/opiates, cocaine, amphetamines, and ecstasy.
While the global rates of substance use have remained stable, the number of people
affected increases with the population, making this an increasingly significant global issue
(UN Office of Drugs and Crime, 2015). Substance use, and in particular injection drug use, is
estimated to be responsible for up to 40% of new cases of HIV and Hepatitis C Virus (HCV)
worldwide, and there has been an increase globally of convictions for substance use related
crimes (UN Office of Drugs and Crime, 2015). Furthermore, there are costs to the health and
wellbeing of the individual PWSUD as well as to health care systems across the globe related

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to overdose, both fatal and non-fatal, as well as other acute and chronic problems related to
substance use (UN Office of Drugs and Crime, 2015; United States Department of Justice:
National Drug Intelligence Centre, 2011).
National and provincial incidence. Canadian rates of substance use have been
estimated using the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS)
(CADUMS, 2015). The survey collects data on alcohol and substance use in Canadians aged
15 years and older. It addresses not only recent use such as in the last month or year, but also
lifetime use of alcohol and controlled substances (Health Canada, Drug and Alcohol
Statistics, 2014). This survey is used for both national and provincial estimates (Health
Canada, Drug and Alcohol Statistics, 2014). The limitations of this survey in providing a true
estimate of the number of PWSUD echo those faced by the UN; it is based on a telephone
survey that relies on self-reporting and thus does not capture those who are street involved
and does not use other forms of data such as hospital data on morbidity and mortality rates, to
support the findings (Zhao, et al., 2012).
Substance use in Canada, including the use of cannabis, cocaine/crack,
amphetamines, ecstasy, hallucinogens, and heroin was reported at 11% in a 2011 CADMUS
survey that measured drug use in the previous year (Zhao et al., 2012). Cannabis is by far the
most used substance with 50% of the population having used cannabis at some point in their
lives (Health Canada, Drug and Alcohol Statistics, 2014). Use of other substances occurred at
such low rates in the general population that they were considered unreliable as data and
thus, not included (Zhao et al., 2012). Conversely, a report prepared by the British Columbia
Centre for Disease Control (BCCDC) compared substance use by the general population
adults and adults living on or near the street and found that the substances of choice different

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significantly between the two groups (Tanner et al., 2014). According to the BCCDC those
living on or near the street are more likely to use crack, crystal meth, and heroin while those
who use substances recreationally are more likely to use cocaine, ecstasy, and magic
mushrooms (Tanner et al., 2014). This demonstrates that the estimated rates of SUD may not
be well represented by surveys that exclude people who are street involved.
Currently, BC is experiencing a fentanyl crisis in which overdose deaths associated
with the use of fentanyl have increased significantly and thus, on April 14, 2016, a public
health emergency was declared (BCCDC, 2017). Fentanyl is a potent opioid narcotic that has
been used to treat pain in hospital settings. The British Columbia Coroners Service (BCCS)
reported in May of 2017 that unintentional and undetermined overdoses, as the result of
fentanyl use, have been rising since 2012 with the steepest increases occurring in 2016 and
continuing into 2017. In 2016, approximately 61.8% of overdose deaths were related to
fentanyl use (Office of Chief Coroner, 2017). While the highest incidence of overdose deaths
occur in the Vancouver Coastal Health Authority region (22.2/100,000 in 2016 and
43.5/100,000 to date in 2017), in the NHA region, the overdose death rates were 17.8/100,
000 in 2016 and to date in 2017 are 14.7/100,000 (Office of Chief Coroner, 2017).
The severity of the fentanyl crisis has brought SUD to the forefront of the minds of
many people. The issue is not resolving organically and the risk for PWSUD is increasing.
The safe injection site on Vancouver’s lower east side reported that approximately 86% of
the drugs they test now contain fentanyl, sometimes unbeknownst to the PWSUD
(Vancouver Coastal Health, 2016). This results in a higher risk scenario for people already
engaging in risky behaviour. The need for increased awareness, resources and support for
PWSUD, and the people who care for them is paramount. Because the resources in the NHA

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region must be dispersed across a vast geography, RNs and other health care professionals
must be very capable generalist practitioners. PWSUD in the north have limited access to
specialized services, particularly in rural centres across the region (Bellringer, 2016). As a
result, PWSUD may access care through other means including EDs which means that
education and training for RNs working in the ED need to address best practices for the care
of PWSUD.
Incidence in northern BC. The NHA has been identified as having some of the
highest rates of substance use in the province (University of Victoria, 2011). The commonly
used substances in northern BC are crack/cocaine, marijuana, and methamphetamine (Tanner
et al., 2014). The high rates of substance use can be attributed to a number of factors
including the low average age of the population and the presence of many industrial camps
(Northern Health, 2012). Additionally, 17.5% of the population of the NHA region identify
as Indigenous. While being Indigenous does not equate to having an SUD, recent data
highlights that there are discrepancies in the rates of SUD and other mental illnesses between
Indigenous people and other residents of the north (First Nations Health Authority, 2014;
Firestone, Tyndall, & Fischer, 2015). Explanations for this are unclear, but the differences
could stem from disparities in the social determinants of health such as: poverty,
unemployment, poor level of education and health literacy, housing challenges, human
geography, and limited access to culturally appropriate health care (First Nations Health
Authority, 2014; Firestone, Tyndall, & Fischer, 2015; Northern Health, 2015). Additionally,
the ongoing impacts of colonization and the enduring intergenerational trauma could be a
contributing factor to this discrepancy (First Nations Health Authority, 2014). For example,
the negative impact of residential schools on survivors has been linked to ongoing social and

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health issues (Paradies, 2016). These disparities, among others, have resulted in Indigenous
populations being “five times more likely to be hospitalized due to psychoactive substance
use” than other residents of BC with aboriginal youth being a population of particular
concern (First Nations Health Authority, 2014; Northern Health, 2015).
The NHA region has a population with a lower average age than any other health
authority in the province (British Columbia Statistics, Population Estimates. 2015). Since the
majority of PWSUD are in the age range of 15-35, this has an impact on the rates of SUD in
this region (CADMUS, 2015). Younger people, particularly those who struggle as a result of
disparities in the social determinants of health such as food security and safe housing, are at
increased risk for initiating substance use and thus suffering from SUD (Bowen & Walton,
2015; Thomas, 2016). Social determinants of health have significant impacts on the overall
health of northern BC residents demonstrated by poorer overall health rates when compared
to the rest of the province (Northern Health, 2015).
Furthermore, the NHA’s geographical region houses a large number of industrial
camps with mobile and transient workforces (Northern Health, 2012). It is estimated that in
2012 there were approximately 1809 camps in the health authority but it is unclear how
many were active and whether there has been any duplication in the estimate (Northern
Health, 2012). They also vary in size from very large to smaller camps. Additionally, there
were 38 current or anticipated mines within the health authority region. Due to the rapid
population increases that communities often experience with resource based economies, the
infrastructure to support the increased population, including those allowing for access to
health care services, is often not present (Badenhorst, Mulroy, Thibault, & Healy, 2014).
Depression, anxiety, and social isolation from both the worker’s, worker’s families, and the

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surrounding communities can be considered as an aggravating factor for substance use
(Badenhorst et al., 2014; Northern Health, 2012). The prevalence of SUD within work camps
can be attributed in part to the culture of the camps; substance use is considered a normative
activity for recreational time (Northern Health, 2012). Since many of the people working in
camps are from elsewhere, they do not have readily available primary care and thus, utilize
EDs for any health care needs including those associated with substance use.
SUD and the Social Determinants of Health
As highlighted in the previous section, the social determinants of health are evident as
important factors and predictors of substance use as well as other adverse health conditions.
The 14 social determinants of health include, but are not limited to, homelessness,
unemployment or underemployment, trauma, education, childhood development, and familial
and social structures; all have an impact on people with SUD related to the initiation of drug
use and attempts to cease use (Galea, Nandi, & Blahov, 2004; Fischer, et al., 2005;
Mikkonen, & Raphael, 2010; Tanner et al., 2014). For example, adverse living conditions
result in increased physiological and mental stress on individuals, which in turn can give rise
to coping mechanisms that may result in negative health outcomes (Mikkonen & Raphael,
2010). Coping mechanisms that can result in negative health outcomes can also include
harmful health behaviours, such as substance use, tobacco use, and alcohol use. These
behaviours may be aimed at decreasing the symptoms, for example the stress, of adverse
living situations. However, these coping mechanisms and behaviours do not address the
underlying source of stress, which may in turn lead to increased stress and a decreased ability
to positively impact the social determinants of health, thus perpetuating the cycle (Mikkonen
& Raphael, 2010).

14

Most important is the recognition that the social determinants of health are socially
constructed and imposed on the individual by the community in which he or she lives
(Mikkonen & Raphael, 2010). The individual may have little control or influence over the
social determinants of health with many factors being “determined by decisions that
governments make in a range of different public policy domains” (p. 7). The individual is the
one who must navigate the social determinants of health to improve health at the personal
level. This can be a daunting task and in order to make large scale improvements to the
health and wellbeing of those who struggle, government level changes must be instituted.
Social Impact of Substance Use
Social costs associated with substance use include issues at the societal level such as
drug related crime, increased incidence of communicable diseases, such as HIV and HCV, in
addition to increased costs associated with hospitalization for substance related health issues
(Public Health Agency of Canada, 2013).
Currently, there is a strict drug policy in Canada (Canadian Drug Policy Coalition,
2013). Consequences for substance related convictions can range from probation and fines to
up to a year in jail for possession of illegal substances and more significant consequences for
trafficking (Enforcement, 2014). As a result, PWSUD are forced to acquire their substances
through underground transactions and also to administer their substances in secret
(Enforcement, 2014; Fischer, 1995). The requirement to hide substance use has a number of
significant impacts on the individual, the community, and society as a whole, and can be
linked to higher levels of crime. Substance use is directly related to 6.6% of all crimes in BC
including crimes such as trafficking and procurement of controlled substances (Sorge,
Buxton, Amlani, & Ishuguro, 2015). There is also a correlation between increased crime and

15

substance use. Crimes such as robbery, murder, prostitution, break and enter, and sexual
assault have been associated with those under the influence of substances and other activities
related to buying and selling controlled substances. (Tanner et al. 2014). Tanner et al. (2014)
pointed out that it is very difficult to accurately estimate the true rate of crime associated with
illicit substance use and that, according to the BCCDC, up to 40% of people incarcerated for
crime have substance use issues.
In addition to crime, SUDs are associated with a number of serious health conditions.
For example, the increase in new cases of HCV and HIV has been closely linked with
controlled substance use, in particular intravenous (IV) drug use. However, use of other
psychoactive substances can increase higher risk behaviour such as unprotected intercourse
resulting in transmission of HCV and HIV (Tanner et al., 2014). IV drug use is second only
to men who have sex with men as the most common source of new infections of HIV and
HCV (Tanner et al., 2014). Northern BC has the highest incidence of new cases of HIV
associated with drug use next to East Vancouver and of HCV next to East Vancouver and
Fraser East (Tanner et al., 2014). This translates into increased costs to the health care system
for the management of these communicable diseases. For example, the lifetime cost of
medications for a person with HIV is approximately $567,000. This number primarily covers
the cost of antiretroviral drugs and hospital admissions for illness directly associated with
HIV (Nakagawa et al., 2015).
Similarly, in 2013, the NHA reported that 862/100,000 hospitalizations were the
direct result of controlled psychoactive substance use in the form of mental health problems,
injury and overdose, and issues listed as other (University of Victoria, 2017; Tanner et al.
2014). This does not account for people who presented to the ED and were discharged

16

without being admitted to hospital; this information was not available through the BCCDC
for the NHA, however, Tanner et al. (2014) indicated that in Vancouver and Victoria the
incidence of PWSUD presenting to the ED was higher than the admissions would indicate. In
addition to hospitalizations, the literature further suggests that when accessing care, PWSUD
tend to require more extensive treatment with a greater number of interdisciplinary health
care providers compared to those that do not use controlled substances (Cenderbaum,
Guerrero, Mitchell, & Kim, 2014).
Access to Care
In the context of this study, access refers to the access to health care and includes
physical access, geographical access, access to culturally safe care, and availability of
specific services. The obstacles that affect availability of services as well as accessibility for
those living on the margins in northern BC must be clearly understood. These obstacles
include vast geography, limited health care dollars that must be used efficiently, and the
number of people living in rural areas with limited access to larger urban centres (Parker,
Jackson, Dykeman, Gahagan, & Karabanow, 2012).
The NHA covers 600,000 square kilometers of land and services approximately
300,000 people (Northern Health Authority, n.d.). Most communities within the NHA region
are considered small urban, rural, or remote, with Prince George (population 94,000) as the
largest urban centre located in the central interior health services delivery area (HSDA)
(Statistics Canada, 2014). The northeast HSDA and northwest HSDA each consist of
numerous rural communities that are relatively isolated from one another and, at certain
times of the year, may be difficult to access due to the harsh climate (De Leeuw, Friske, &
Greenwood, 2002). The largest community in the northeast HSDA is Fort St John

17

(population 37,495) and in the Northwest, Prince Rupert (population 13,274). Other rural
communities in these regions may range from as few people as 303, upwards (Statistics
Canada, 2014).
While access to care is an issue for all people with SUD, northern BC has a number
of additional barriers to accessing appropriate care in part due to the dispersed geographical
region and due to the lack of ready access to specialized care. Given this vast geography and
the distribution of people across it, health care dollars must be allocated in a way that
maximizes service provision (Parker et al., 2012). This can make it difficult for people living
rurally to access specialized care. Additionally, the unpredictable weather that northerners
encounter for six to eight months of the year makes access to services even more difficult to
obtain. As a result, new and imaginative ways of providing care to those who may be socially
or geographically marginalized is necessary, and EDs have become part of the solution for
clients to gain access to care.
In northern BC, EDs are often a point of entry for PWSUD to access health care
(Kennedy, Curtis, & Waters, 2014). EDs in the north vary in the level of care they can
provide from Trauma Centres at University Hospital of Northern British Columbia
(UHNBC) (Level III), Mills Memorial Hospital and Ft. St. John Hospital (Level V) to EDs
that are not designated as trauma centres and thus treat clients with urgent and emergent care
needs as they are able and transfer out those patients who have needs beyond the capacity of
their departments (Trauma Association of Canada, 2012). RNs working in EDs across the
continuum of care will provide care to PWSUD, therefore it is important to understand the
intended role of the ED and nurses who work in them.

18

Role of ED and ED Nursing
EDs are unlike any other health care setting in that they have client intake 24 hours a
day and no client is denied service, “even when the hospital is at capacity” (Quattrini &
Swan, 2011, p.40). Clients can present to the ED with illness and injuries that range in acuity
from coughs and colds, to higher acuity complaints such as abdominal pain, chest pain, or
trauma. In addition to the clients who present with urgent issues, the ED is also used as a
portal of entry to the health care system for other patients who lack access to appropriate and
timely primary care (Uscher-Pines, Pines, Kellerman, Gillen, & Mehrotra, 2013).
Role of the ED. The purpose of the ED is to provide care to those that present with
immediate health needs and then move people into areas where their health needs can best be
managed on an ongoing basis; this might be admission to hospital or referral to communitybased services for care (Derlet, Richards, & Kravitz, 2001). As a result, professionals
working in the ED “have no control over the type of patients who present for care, the pace
of their arrival, or the acuity level” (Quattrini & Swan, 2011, p.40). Clients are typically
unknown to the RNs and other health care providers and their ailments are commonly
undiagnosed at admission, exposing ED nurses to an unpredictable clinical environment
(Adriaensens, De Gucht, & Maes, 2015; Hosking, Considine, & Sands, 2014).
ED nursing. RNs working in the ED must be able to care for each client’s physical,
psychological and social health in a timely way (Kennedy et al., 2014). As a result,
emergency nurses must be able to adapt quickly to changing situations and have a broad and
varied knowledge base from which to draw when making clinical decisions.
People experiencing SUD access EDs for a host of reasons including injury resulting
from substance use, infections, mental health support, and other health issues related to, and

19

unrelated to, substance use. RNs working in EDs must be have knowledge related to the
specific needs of people experiencing SUD and be skilled in the management of, what can
be, challenging situations related to the complex needs of people experiencing SUD (Ford,
Bammer & Becker, 2008).
Context and Purpose
The disparity of services specific to PWSUD, along with other health services and
supports, became evident to me through my work as an RN in the ED at UHNBC. In my own
nursing practice, I noticed that PWSUD commonly presented to the ED during situations of
crisis in relation to their substance use. While their immediate and urgent needs would be
addressed, clients were routinely left without specific plans for follow up or SUD treatment
once discharged; this would leave them at risk for increased harm related to their substance
use (University of Victoria, 2016). PWSUD require specialized care that spans not only acute
care settings, but also community follow up care (Bystrek, 2010).
Nurses in the ED are well situated to assist PWSUDs to access health care services
(Kane et al., 2016). This is due to RNs’ frequent, and sometimes regular, contact with
PWSUDs who access health care through the ED. With detailed knowledge of navigating the
health care system, the availability of resources and the ability to refer clients to appropriate
services as necessary, ED RNs could act as facilitators for PWSUD to access immediate and
ongoing care (Kane et al., 2016). Discharge planning is firmly in the domain of the RN
regardless of the area of practice and RNs must have the knowledge and ability to direct
PWSUD to appropriate and timely resources upon discharge, as they would with any other
patient (Sexson, Lindauer, & Harvath, 2017). The purpose of this research was to gain insight
into nurses’ perspectives, their beliefs about their role in caring for PWSUD and what can be

20

done to support excellence in ED nursing care of those suffering with SUD. A review of the
literature is presented in the next section to provide further context for the study and to
provide an overview of the existing literature.

21

Chapter 2: Literature Review
The use of substances, including controlled drugs, is creating significant challenges
both in Canada and internationally. As health care services struggle to keep up with the
demand, health care providers are further challenged to care for patients in the absence of
accessible resources and supports. These challenges are further complicated in small urban
and rural settings where access to appropriate services may be more limited and supports
more sparse. Nurses working in the ED are commonly faced with the need to care for
PWSUD typically in a crisis or emergent situation. However, it is unclear how nurses
experience caring for those with SUD. The following chapter provides an overview and
synthesis of the literature review methods. This provides an important contextual foundation
to the research and was used to inform the development of the research study. First, an
overview of the review methods and literature search strategy is presented, followed by the
review of the findings.
Review Methods
An integrative review of the contemporary literature was undertaken to explore what
is known about RNs’ and other health care professionals’ experiences, knowledge, attitudes,
and beliefs toward people with PWSUD and SUD and how these attitudes and beliefs are
formed. An integrative literature review approach is adopted here as a mechanism to
critically appraise and summarize the existing evidence and to identify gaps and areas for
further research (Fink, 2010). While this review methodology is not as rigorous as other
highly structured reviews such as systematic reviews and metasyntheses, it allows for the
inclusion of a diverse range of research literature from multiple methodological standpoints
and can highlight important considerations and innovations from the practice setting

22

(Whitmore & Knafl, 2005). This integrative review was undertaken in four stages: 1)
development of the search strategy, 2) preliminary review of the literature, 3) focused search
of the literature and 4) analysis and reporting. The stages will now be presented.
Stage One: Development of the Search Strategy
The purpose of developing a search strategy is to ensure that an organized and
thorough search of the literature is completed. An organized literature search allows
increased understanding about the subject of interest and ensures that the key literature
sources are captured and included. Organizing and documenting the search strategy allows
the search to be replicated or amended as needed (Burns, Grove, & Gray, 2011). The purpose
of this literature review is to inform the investigation of the research question: what are the
experiences of Registered Nurses caring for people with substance use disorders in an
emergency department setting? As part of the process of developing the search strategy, time
was taken to select the most appropriate electronic databases and search terms for the review.
Electronic databases and search terms. A comprehensive review of the literature
was undertaken through the University of Northern British Columbia (UNBC) Library.
Databases were searched to ensure the greatest breadth of literature was captured. Five
databases were selected for this electronic search: Pubmed, Medline OVID, the Cumulative
Index to Nursing and Allied Health Literature (CINAHL), PSYCHinfo and Science Direct.
Selection of key words and medical subheadings (MeSH) was completed using a trial
and error process. I originally intended to limit the search terms to identify literature specific
to EDs, however this resulted in very few articles. The search terms were then expanded to
enable a broader search of the literature. All databases were searched using the following
MeSH or keywords: substance abuse (MeSH), substance use disorder (MeSH), illicit drugs,

23

harm reduction (combined with the Boolean Phrase AND), nurses, and experiences. When
these keywords were combined using the Boolean phrase ‘AND’, they produced no articles
in any of the five databases.
In order to broaden the search, physicians, attitudes, beliefs, and views were added as
keywords, and work experiences was added as a MeSH. Nurses and physicians were
combined using the Boolean ‘OR’ as were experiences, views, attitudes and beliefs. These
combinations were then combined with the MeSH substance abuse OR substance use
disorder OR illicit drug use OR harm reduction using AND (see Appendix B for diagram).
All keyword searches were undertaken using the keywords as major concepts and in the
searches where appropriate, MeSH were used. MeSH were both exploded and searched as
major concepts wherever able. Following the preliminary search in early 2015, 390 articles
were identified from screening and preliminary review.
Stage Two: Preliminary Review of the Literature
Once the initial database search was completed, the articles were screened for
relevance, duplicates removed and the remaining articles underwent a preliminary review
according to the eligibility criteria. To be eligible for inclusion, the articles needed to be
available in English, appear in peer reviewed journals, and contain subject matter that
addressed nurses’ and/or physicians’ experiences, attitudes, views, and/or beliefs. Articles
that were based on North American, European, or Australian populations were included due
to their similarities to the Canadian context. Articles written prior to 2000 and those
considered to be not relevant to the Canadian context or ED were excluded. Articles that
explored nurses’ attitudes and perceptions of specific populations of PWSUD, such as

24

pregnant women and people in correctional facilities, were also excluded to increase the
focus on SUD rather than characteristics of subpopulations of PWSUD.
Stage Three: Focused Review of the Literature
Using the inclusion criteria, 47 articles were selected at the screening stage. A further
review of the abstracts was completed to narrow down the articles (32). The full text articles
were then retrieved and critically appraised using the processes provided by Davies and
Logan (2012) followed by a full text review resulting in a final cohort of 22 articles. An
expanded review was taken of the final 22 articles during which I collected a variety of
information about each article including the study design, the outcomes and measurements
and the findings. These were amalgamated into a literature matrix (Appendix C). In the
summer of 2017 the search was executed for a second time to identify new literature
emerging from the field. This search resulted in the inclusion of six additional articles.
Stage Four: Analysis and Reporting
A total of 28 articles were critically appraised for content and then organized
thematically. In 19 of the articles, the attitudes, beliefs and knowledge of health care
professional related to substance use (Personal) were the focus, six articles focused on the
impact of interpersonal relationships between the health care worker and the client in the
health care setting (Interpersonal) and four articles addressed the importance of the role of
organizational support (Organizational) in providing adequate care to PWSUD. The literature
was appraised for its methodological strengths and weaknesses and the key findings
identified.

25

Literature Review Findings
Review of the literature yielded 28 articles that were selected based on the criteria
provided above, and critically appraised. The analysis of the literature led to the
identification of three major themes. These themes are personal, interpersonal and
organizational perspectives.
Personal Attitudes and Beliefs about SUD
Personal perspectives emerged as an important theme in the literature relating to
substance use. This theme included literature that described health care professionals’
attitudes, beliefs and knowledge about PWSUD, and providing care for SUD. Since the
literature focused only on RNs was limited, literature that investigated the beliefs of other
health care professionals has been included. Nineteen studies were reviewed and five are
presented here in detail, as these were the most robust and relevant studies. The Kelleher and
Cotter (2008) study was selected for its focus on the ED, the Chu and Galang (2013) was
chosen for its Canadian context and the acute care setting, and the Morley, Briggs, and
Chumbley (2015) study was included for its focus on pain management. Two literature
reviews were included (Adams, 2008; Kelleher 2007) for their cumulative findings and
finally, Mclaughlin, McKenna, Leslie, Moore, & Robinson, 2006) was reviewed in detail for
its focus on multidisciplinary health care professionals. The remaining ten studies from the
initial search and five from the subsequent 2017 search were discussed in less detail due to
their similarities to the four primary studies.
Emergency Department context. A single article, the Kelleher and Cotter 2008
study, is presented in this section. It was the only study identified that looked specifically at

26

the attitudes, beliefs, and knowledge of RNs in an ED setting. While a very small number of
physicians participated in this study, the vast majority of participants were RNs.
Kelleher and Cotter (2008) undertook a descriptive survey study to explore the
knowledge and attitudes of ED doctors and RNs toward substance use and PWSUD. A
modified version of the Substance Abuse Attitudes Survey was used to assess current and
perceived levels of knowledge related to PWSUD and attitudes toward substance use and
PWSUD. Further, the authors sought to understand health care providers’ perceived roles in
caring for PWSUD as well as the frequency of interactions with clients who use controlled
substances. A convenience sample of doctors (n=5) and RNs (n=61) were included in the
study. Participants were recruited through managers and word of mouth from three university
teaching hospitals in Ireland. The sample was primarily female, with a majority of nurse
participants having less than 10 years of clinical experience. Most of the nurses in this
sample (73.8%) had no specific training related to substance use and alcohol use; those that
had received previous training (19.7%), received this through workplace in-services as
opposed to pre-registration educational courses or as part of workplace preparation.
Data were analyzed using the Statistical Package for Social Sciences (SPSS)
including descriptive statistics to evaluate the characteristics of the study population and the
attitudes of the health care professionals. A key benefit of this study was the use of an
established tool where the validity and reliability had already been verified. For example,
using Cronbach’s alpha test for reliability, they found that participants reliability was high (α
= 0.77) particularly related to perceived competence (α = 0.86). Validity was analyzed using
Pearson’s correlation and significant correlation between perceived and actual knowledge
was demonstrated (r = 0.30; p = 0.018).

27

The analysis of the results of this survey showed that the majority of respondents
believed that PWSUD were adequately managed in EDs however, a lack of services was
identified as a key barrier to providing optimal care. Levels of knowledge were shown to be
adequate, with the majority of respondents perceiving that they were moderately
knowledgeable (95%) and competent (90%) in identifying SUD. 41.9% of respondents
reported being “a little” competent and 43.5% reported good awareness of specialty services
and referral processes. Further, perceived competence was also low with regards to brief
interventions with 47.6% of respondents identifying as only a little competent. According to
Babor and Higgins-Biddle (2001) a brief intervention can be done in a 5 -30 minute time
span and is directed at motivating those with substance use disorders to reduce or cease use
of substances. It is not usually directed at those with mild SUD, except to encourage people
to access more intensive treatment. 93.7% of respondents agreed that ED health care
providers had a legitimate role in the care of PWSUD.
The attitudes survey in Kelleher and Cotter’s 2008 study in Ireland measured attitudes
in five areas in terms of permissiveness. The majority of respondents held views consistent
with an abstinence based ideology. An abstinence-based ideology focuses on the cessation of
substance use and preventing a relapse back into substance use and is one of the two primary
ideologies that guide the care of PWSUD (van der Woerd, Cox, Reading & Kmetic, 2010).
They did however, show some increased levels of permissiveness with regard to cannabis.
Respondents recognized the importance of early intervention as well as long term care for
SUD. Most respondents agreed with treatment programs (87.6%) and lifelong abstinence
(73.9%) as necessary to success in treatment. Despite this, respondents were overwhelmingly
in disagreement with statements that demonstrated stereotypical representations of PWSUD.

28

However, only 55.6% disagreed with the statements that depicted PWSUD as unpleasant to
work with. Interestingly there were no questions related to non-abstinence based treatments
in the article.
The key points made through Kelleher and Cotter’s (2008) research were that while
ED doctors and nurses have nearly daily contact with PWSUD, they usually have little or no
formal training in managing their care. These health professionals identified that the care of
PWSUD is inadequate and cite a lack of available services as the primary reason. Finally,
Kelleher and Cotter (2008) found that although emergency physicians and nurses in this
study were not permissive of substance use, they displayed positive attitudes that aided in
developing constructive, therapeutic relationships with PWSUD.
Kelleher and Cotter’s (2008) study had some limitations. First, the assumption of an
abstinence-based ideology was evident in the study. In limiting the questions to concepts that
fit this ideology the research may have failed to capture other important data or perspectives.
Second, the study was conducted using a small number of respondents (n=66) almost all of
whom were RNs (n=61). The study was conducted in a single county in Ireland, in centres
that were largely urban with teaching hospitals. Thus, transferability to other contexts,
particularly rural settings, other jurisdictions, or countries may be limited. Third, the survey
relied on self-report methods. It is not possible to know if these views are reflective of actual
practices or if responses were be impacted by socially acceptable answering and poor insight
into personal bias. However, the article does focus specifically on the ED environment and
provides some key insights related to the training and support needs of health care
professionals and represents the only article that provided this information. Finally, the

29

authors did not compare the demographic characteristics to the wider nursing population
making it difficult to assess the representativeness of the sample.
Canadian context and RN specific context. The review of the literature yielded
only one study conducted in a Canada hospital (Chu & Galang, 2013). Other studies included
in this section are used to support the findings of Chu and Galang, in regards to their findings
of nurses’ attitudes, beliefs, and knowledge about SUD and PWSUD in an acute care setting.
In the Canadian study by Chu and Galang (2013), the attitudes and perspectives of a
convenience sample of 73 RNs toward PWSUD in a single medical unit in an urban hospital
in Toronto were explored. Using the Drug and Drug Problems Perceptions Questionnaire
(DDPPQ), a pencil and paper tool, they sought to collect information on job satisfaction, role
specific self-esteem, role legitimacy, and role support in relation to caring for PWSUD.
Participants were recruited using convenience sampling with a response rate of 73%. Similar
sample characteristics to the Kelleher and Cotter (2008) study, where the sample was
primarily female (90%) with an average of 9.3 years of nursing experience were found. The
data collected using the DDPPQ survey was analyzed first by the researchers, by hand and
then entered into SPSS where relationships between variables were assessed using chisquare, Pearson correlation and regression analyses. Significance was set with a p value of
0.05 due to the potential for type I error.
Chu and Galang found that nurses held a basically neutral view of PWSUD. The
average score on the survey was 62.5/140 which according to questionnaire norms, indicates
the participants held neither negative nor positive views. The authors recognized that the
results of this study differed from other similar studies, in which the participant views were
more negative in nature, and that the results would be of limited generalizability due to the

30

single location of the sample. They associated the neutral attitudes of the nurses to the
influence of the local culture of substance use on the health care system and the daily contact
that the nurses had with PWSUD. There were several findings that made this study
significant to this review. First, the study highlighted that lack of organizational support was
a potential barrier to improving attitudes, beliefs and knowledge about PWSUD and SUD in
addition to the lack of education and training in SUD issues. These findings were consistent
with other studies captured in this review (Adams, 2008; Ford, 2010; Happell, Carta, &
Pinikahana, 2002; Harling & Turner, 2012; Kelleher & Cotter, 2008; Lovi, & Barr 2009;
Morgan, 2006). Second, the authors identified that contact with PWSUD may be an
important variable for improving the therapeutic attitudes of nurses toward PWSUD. While
the study has a number of limitations, including being undertaken in a single unit in a large
urban centre and being reliant on self-report; it is the only study that has examined this issue
in Canada. Furthermore, it highlights some of the broader organizational issues that help
explain some of the challenges faced in managing this population.
In a quantitative study of RNs from Australia, Happell et al. (2002), like Kelleher and
Cotter (2008), used the Substance Abuse Attitudes Survey to assess the knowledge and
attitudes of RN’s. Their sample consisted of RNs working in MH&A settings and they found
that although the RNs tested as having adequate knowledge, their reported perceived
knowledge was less than adeuqate. The analysis of the findings further identified that the
participants did however, have more positive attitudes toward substance use and PWSUD
than those in the general population of nursing. They also found that RNs were more likely
than physicians to screen for substance use when assessing their clients.

31

Pinikahana, Happell, and Carta (2002) gave a modified version of the Substance
Abuse Attitudes Survey to members of a Substance Use and Mental Illness Treatment Team
(SUMITT) in Melbourne Australia. Thus, as in the previous study, the focus was MH&A
professionals (n=173) from both rural and urban areas. No distinction was made in the results
between rural and urban respondents. Interestingly, due to its focus on mental health
professionals more of the respondents were male and 134 were RNs. The findings concurred
with those identified by Kelleher (2007), in that the majority of the health care professionals
demonstrated intolerance of substance use. They were however, optimistic that treatment is
effective especially when SUD is identified early and appropriate ongoing care is provided.
The two previous studies served to support the conclusion that overall, health care
professionals have a demonstrated intolerance towards substance use.
In the interest of understanding how nurses first develop their attitudes and beliefs
about PWSUD, nursing students’ attitudes were explored in a study by Harling and Turner
(2012). Using a qualitative approach, they looked at student nurses and their attitudes toward
substance use u. They found that the students at one particular school of nursing in the
United Kingdom (UK) had a low regard for substance use and that the influences on student
attitudes originated in a variety of sources including personal experiences, societal norms,
lack of formal education, and contact with working nurses who exhibited negative attitudes
(2012). These findings are echoed in Ford (2010) where survey data from nurses were
compared with that of the general public. How nurses’ attitudes develop is significant in that
attitudes and beliefs will impact interactions between nurses and PWSUD and thus contribute
either positively or negatively to the experiences of nurses who care for PWSUD.

32

Pain management in SUD. While many of the studies from the initial review of the
literature assessed the general attitudes that nurses and other health care professionals held
toward PWSUD, the subsequent review of articles, from 2014 to summer 2017, yielded 3
articles that were targeted at specific experiences such as the care of PWSUD in pain.
A descriptive phenomenological study, by Morley, et al., (2015), examined United
Kingdom nurses’ experiences of caring for patients with SUD who are in pain. This was
conducted using a convenience sample of RNs from a variety of clinical backgrounds. The
participants underwent semi structured interviews.
The data from the interviews were organized into several themes including “patient
characteristics,” “patient management,” “pressures and targets affecting pain management,”
and “psychosocial factors”. While this study was limited to nurses caring for PWSUD in
pain, this study lends some insight into the difficulties that nurses experience in caring for
this group and the specific needs of this group. Furthermore, this study identified that the
educational needs of the nurses are not necessarily being met, resulting in lower levels of
care for those with PWSUD. Additionally, the participants in this study noted that PWSUD
often have complex social backgrounds that need to be taken into account when planning
care.
Strengths of this study were that it was very ‘data-driven’ in that the description is
rooted in the data, and the authors were diligent in reporting the methods used to ensure
trustworthiness. Limitations were that the sample was homogenous in terms of gender and
was recruited from a single geographical location (Morely, et al., 2015).
In a grounded theory study, Morgan (2014) investigated the attitudes of American
nurses caring for PWSUD with pain. The study was conducted using semi structured

33

interviews that addressed the difficulties experienced by nurses caring for PWSUD in pain,
problems encountered in interactions with PWSUD in pain, and whether they agreed with a
model that had been described by the author in a previous paper. The 2014 Morgan study
included a sample of 14 participants, 12 female and two male RNs working in an urban
public hospital. Once all the interviews had been completed a final interview was conducted
with an expert in the field of addictions nursing. The author described how credibility,
dependability, transferability and confirmability were managed throughout the process.
The result of this grounded theory study was a model that described nursing attitudes
toward patients experiencing SUD and pain (Morgan, 2014). The model described the two
primary categories that affected the experiences and attitudes of nurses, these were
labeling/not labeling pain behaviour and encountering barriers to the provision of care. These
categories described the impact of the label drug seeking and the perceived barriers such as
staffing patterns, level of acuity, contact with prescribers, policies, and lack of resources that
nurses face in caring for PWSUD in pain (Morgan, 2014). The study also outlined some of
the factors that contribute to the nurses attitudes toward pain in SUD. The contributing
factors included the nurses own existing attitudes about both pain and SUD, patients’ pain
behaviour and the impact of reacting to and understanding the patients’ behaviours.
Ultimately this study provided insight into the educational needs as well as the need
for further research to assist in improving nursing care for PWSUD who are experiencing
pain. The study provides a good grounding in understanding what can impact the experience
of nurse caring for PWSUD and pain, but much of this information can be transferred to any
scenario where PWSUD are being cared for in a tertiary health care setting.

34

While the Morgan (2014) article and the Morely et al. (2015) article addressed
nurses’ attitudes, Korkmyrdal and Andenaes (2015) conducted a study to evaluate nurses’
competence in managing the pain of people with opioid use disorder. The researchers
collected a survey from a purposively selected sample in Western Norway. Their only
inclusion criteria were that the participants be registered nurses and that they regularly
worked with people with opioid use disorder. The researchers collected 98 surveys with a
response rate of 54%. All were collected during a two week period in 2010. The surveys
collected demographic data including whether the participants worked full or part time, had
extra education or specialty training, years of experience as a nurse, and experience of caring
for patients with opioid use disorder. Further to the survey, Korkmyrdal and Andenaes
looked at nurses’ sources of knowledge, nurses’ knowledge and skills related to recognizing
and evaluating pain and pain management as well as nurses’ attitudes about the lifestyles of
people with opioid use disorders (Korkmyrdal and Andenaes, 2015).
The data were analyzed using frequency analysis, sum scores and Spearman rank
correlation. In order to investigate the impact of the different factors impact on competence, a
multiple regression analysis was conducted. SPSS Statistics 19 was used for the analysis. The
participants ranged in age from 22-54 years, and worked on two kinds of units: medical and
orthopedics (37.7% and 65.3%, respectively). They had worked as nurses from 0-27 years.
64% had five years or less work experience as a nurse while 69% had five years or less
experience with people with opioid use disorders. The vast majority of the participants felt
confident in their ability to identify and treat pain, and evaluate pain management techniques
(Korkmyrdal and Andenaes, 2015).

35

Experience treating the pain reported by patients with opioid use disorder was most
closely correlated with competence. It was eliminated from the regression analysis (Rs =
0.32, p = 0.001). The results of this study demonstrated that most nurses felt they had
inadequate levels of competence when caring for people with opioid use disorders and
recommended increased educational interventions to address this. Krokmyrdal and Andenaes
(2015) stated that “pain treatment to patients with [opioid use disorders] may be
characterized as a complex task requiring a high level of competence” (p. 792).
This was a cross sectional study which means that it is a snapshot in time and if it
were conducted again, the results may differ. That being said, it brings to light the
importance of learning about pain and the PWSUD, and the increased complexity of caring
for this group in a hospital setting.
Literature reviews. While Kelleher and Cotter (2008) analyzed ED nurses’
perspectives and Chu and Galang (2013) studied the perspectives of RNs on a medical unit,
Adams’ (2008) literature review from the UK, like Happell et al. (2002), looked specifically
at specialty health care providers; in particular MH&A nurses working with PWSUD. This
literature review described the attitudes of nurses working with people with mental illness
and other concurrent morbidities in a variety of settings. The study showed that, although
regard for substance use may be higher than in the general population of health care
providers, it was still low when compared with regard for other client groups such as those
suffering from diabetes or heart disease. Interestingly, Adams (2008) found that those
working in forensics had the poorest attitudes toward substance use and PWSUD in
comparison with those working in other MH&A settings. This contradicts other studies
which highlighted contact with PWSUD as the most predictive variable for the development

36

of positive attitudes (Chu & Galang, 2013; Kelleher & Cotter, 2008; Howard & Holmshaw,
2010; van Boekel, Brouwers, van Weeghel & Garretsen, 2014).
Similarly, prior to the 2008 Kelleher and Cotter study, Kelleher (2007) undertook a
literature review that reviewed evidence related to health care professionals’ attitudes toward
PWSUD. Using the key words knowledge, attitudes, drug abuse, drug misuse and substance
abuser, Kelleher searched five electronic databases as well as a number of governmental
sites, finding 34 articles that were related to this topic. In contrast to the later study by
Kelleher and Cotter (2008), the analysis of the articles, Kelleher (2007) found that health care
professionals in general practice areas identified caring for PWSUD as difficult and
unpleasant. Further, the findings revealed that societal attitudes toward SUD, which in
general are quite negative, were also reflected in the literature relating to the attitudes of
health care professionals. These findings were supported by the findings of Ford’s (2010)
cross sectional study, which demonstrated that nurses’ attitudes in Australia matched fairly
closely with those of the general population. Furthermore, Kelleher (2007) identified several
papers that commented on the detrimental impact of negative attitudes toward PWSUD in
terms of disengagement and avoidance of PWSUD on the part of health care professionals
(Chappell and Schnoll, 1977; Fisher, Mason, Keeley, & Fisher, 1975; Lindberg, Vergara,
Wild-Wesley, & Gruman, 2006).
In Kelleher’s (2007) review, several studies were identified that explored the specific
perspectives of physicians. For example, van Boekel, Brouwers, van Weeghel and Garretsen
(2014) undertook a study of family doctors as well as MH&A specialists and found that there
was generally a low regard for substance use; however unsurprisingly, attitudes were better
among MH&A specialists. They found that the most influential variable to account for the

37

difference was frequency of contact with people with SUD. Similarly, Johnson, Booth and
Johnson (2005) in their survey of physicians, found that generally, there was a low regard for
PWSUD when compared with other client groups. As highlighted, the review was expanded
to explore the perspective and attitudes of other health care providers, such as physicians.
The findings are generally consistent with respect to provided perspectives of a lack of
tolerance for substance use and low regard for PWSUD.
Kelleher (2007) noted the paucity of literature related directly to emergency nurses
and doctors and went on to address that gap in the body of literature. Due to the lack of nurse
specific articles, Kelleher (2007) also focused on studies that evaluated the attitudes and
knowledge bases of physicians and other health care professionals; the same has been done in
this review. The following paragraphs will investigate physicians’ and other health care
professionals’ perspectives to provide a more fulsome understanding of the attitudes toward
PWSUD that exist within the health care system.
Multidisciplinary studies. Kelleher’s 2007 findings were also corroborated by
Raistrick, Russell, Tober, and Tindale (2008) who used a modified Alcohol and Alcohol
Problems Perceptions Questionnaire (AAPPQ) to examine the perceptions of a variety of
health care professionals. The AAPPQ was modified to include substances as well as alcohol.
In this survey study, physicians were found to have the lowest regard for substance use. The
authors found that health care assistants were the most tolerant of substance use and that RNs
held intermediate positions. The findings of this study are interesting because those with the
highest levels of education or responsibility had the least regard and those with the lowest
level of education held the highest regard (Raistrick et al., 2008).

38

Mclaughlin, Mckenna, Leslie, Robinson and Moore (2006), examined the experiences
and perceptions of a purposive sample of 32 Irish health care providers (including RNs,
general practitioners, health visitors, social workers, health promotion workers and health
centre managers) in relation to PWSUD. In this focus group study, participants were asked to
share their level of experience and training with respect to PWSUD and to explore factors
related to role legitimacy. The focus group interviews were transcribed verbatim and
analyzed thematically using Burnard’s guidelines (Burnard, 1991).
While some key themes were identified, the analysis of the findings revealed
significant diversity in the attitudes and opinions held. Role legitimacy was identified as
being particularly problematic. For example, some of the participants did not wish to have
involvement with PWSUD and avoided education and training related to substance use for
fear of being identified as an expert. No participant suggested that primary care was an
appropriate setting for the care and treatment of this group. At the same time, education and
training was identified as a barrier to providing care to PWSUD. There was general
pessimism about the efficacy of treatment as well as a dehumanization or stigmatization of
PWSUD as only being interested in involvement in their health care, “as long as they get
what they want” (p. 685).
McLaughlin’s et al. (2006) qualitative study lends a great deal to the body of
literature in that it was able to capture conversations about health care professionals’ care of
PWSUD. Furthermore, the number of participants was quite large for a qualitative study.
Furthermore, focus groups have some limitations and some dangers in that a dominant
personality or a person in a position of power can influence the conversation (Connelly,
2015). However, in this case, the themes were reiterated through six different focus groups

39

and reflected the findings of other related studies (Howard and Holmshaw, 2010). While the
aim of the article states that the experiences of health care professionals were of interest, little
in terms of actual care of clients was discussed. The focus of the McLaughlin et al. (2006)
study differed from the focus of my research study, as my study focused on the experiences
of RNs in EDs however, the McLaughlin et al. (2006) study offered some insights into the
perspectives and experiences of health care providers working with PWSUD. This was a gap
in the literature which my study has addressed.
Similar to the McLaughlin (2006) study, in their 2010 mixed methods study, Howard
and Holmshaw (2010) examined the barriers identified by multidisciplinary staff in the
management of mental health clients who used substances. The participants were recruited
from one assessment and admissions units, five mental health treatment units, and three
residential mental health units in England. Of the survey participants, who self-identified to
participate, ten interviews were conducted with individuals chosen to represent a cross
section of the wider population.
The Howard and Holmshaw (2010) study survey collected demographic data and also
included DDPPQ. The interviews covered the experiences of health care professionals in
working with people with dual diagnoses, team work, accountability and responsibility,
support and professional training (Howard & Holmshaw, 2010). Participants were able to
provide their views on barriers to the provision of care.
The questionnaire demonstrated that there was no difference between the groups
working in acute or residential care. There was a statistically significant difference in
therapeutic attitude between those that had received education related to dual diagnosis
clients and those who had not. Those who had received the education were more likely to

40

have a favorable attitude toward the population. The participants identified clinical
supervision, team/group supervision, education, and support from the expert dual diagnosis
group as areas that needed to be improved (Howard & Holmshaw, 2010).
The interviews revealed that the participants identified seven themes related to
barriers to working with PWSUD. The seven themes were: working with PWSUD; team
attitudes; trust policies and local area protocols; concerns with legality; staff support
structures; training; and team communication and problem solving within multidisciplinary
meetings.
In the community health context, Gasman and Weisner (2005) used semi-structured
interviews to assess regard for substance and alcohol use among community-based health
care providers including social workers, counselors, physicians, nurses, and dentists among
others. Their findings highlighted a discrepancy in definition of abuse or misuse of drugs and
alcohol but also that most community health care providers held a lower regard for substance
use when compared to alcohol use. According to the authors, this is indicative of a culture
where SUD associated with alcohol use is perceived as a social problem and SUD associated
with controlled substances is perceived as a personal failing (Gasman & Weisner, 2005).
A third article by van Boekel, Brouwers, van Weeghel, and Garretsen (2015) was
located during the 2017 search of the literature, this study was aimed at assessing and
comparing the stigmatizing attitudes towards PWSUD among the general public, general
practitioners (GPs), MH&A specialists and clients in treatment for SUDs. A variety of
methods was used to collect the surveys. Three of the sections of data were collected using
random sampling; the general public had a response rate of 75.7% (n=2, 793), GPs 23%
(n=180), MH&A specialists 74.6% (n=167). Clients with PWSUD were recruited using

41

convenience sampling and a sample consisting of 186 clients participated. All participants
responded to the same questionnaire. The survey explored stereotypical beliefs, attribution
beliefs, expectations related to rehabilitation and social distance.
In order to make the samples from the different subgroups comparable statistically, a
random sample of 190 surveys was selected from the large number of surveys from the
general public in order to use a parametric analysis. SPSS Statistics 19 was used for the
analysis of the data with a p value of ≤ 0.01. Descriptive analysis was employed to examine
stigmatizing attitudes. ANOVAs were used to compare stereotypical beliefs, attribution
beliefs, expectations of rehabilitation, and social distance. Multiple linear regression analysis
was performed to predict social distance toward PWSUD with the variable age, gender,
stereotypical beliefs, attribution beliefs, and tendency to answer in a socially desirable way.
In total the responses of 723 individuals were included in the analysis.
Overall, van Boekel et al. (2015) found that people from all groups held basically
neutral opinions towards most of the stereotypes presented. An exception to this, was the
stereotype describing PWSUD as self-neglecting and tend to be aggressive where many
participants agreed. Most participants believed that individuals could not control their SUD
and that SUDs can be successfully treated. Most agreed that SUD is a disease, however all
groups reported a high tendency to maintain social distance from PWSUD.
Similar to the 2007 Raistrick et al. study, in 2015, Raistrick, Tober and Unsworth
conducted a second round of AAPPQ surveys that looked at therapeutic attitudes of nurses
(150), doctors(41) and health care assistants(67), working in a general hospital, towards
PWSUD. The AAPPQ scale looks at “role adequacy- feeling one has the knowledge and
skills to help; role legitimacy – feeling that intervening with addiction problems is a

42

legitimate part of one’s role; positive outcome expectancy - a belief that people can recover
from SUD; [and] self-efficacy – a belief in one’s ability to change a patients’ outcomes
related to substance use” (2015, p. 1475).
The authors distributed 1175 questionnaires to seven wards where a training program
aimed at improving identification, and engagement skills as well as encouraging improved
attitudes towards treatment outcomes for PWSUD was implemented. The survey had a 24%
return rate (288) of which all but 16 were complete (n=258). The authors attributed the low
response rate in part to limitations placed on the researcher related to recruitment by the
ethics review boards due to the sensitive nature of the data (Raistrick et al., 2015).
The results demonstrated negative overall therapeutic attitudes across all three groups
of health care professionals with doctors have the lowest regard for SUD and health care
assistants having the highest regard. Younger doctors, those under 30 years, scored more
positively than older doctors. Nurses scored intermediately. The authors noted that the results
of this survey were similar to those of the previous survey and that while the training
program that had been occurring concurrently with this was linked to improved overall
therapeutic attitudes scores overall attitude were still low (Raistrick et al., 2015). The area
where health care professionals continued to score lowest was role legitimacy prompting the
authors to recommend that treatment for SUD not be enveloped in all other specialties or
general care but be provided by specialists. Given that EDs see many PWSUD for a variety
of care needs; this is a significant recommendation that has not been seen prior to this article.
Summary. While the studies captured in this review are methodologically diverse
and include a range of health care providers, all have identified the need for improved access
to education and training as a means of addressing attitudes and perceptions about PWSUD.

43

While higher regard for this client groups was reported in those with more frequent contact
(Chu & Galang, 2013; Kelleher & Cotter, 2008; Howard & Holmshaw, 2010; van Boekel,
Brouwers, van Weeghel & Garretsen, 2014) and formal training (Adams, 2008; Ford, 2010;
Happell et al., 2002; Harling & Turner, 2012; Kelleher & Cotter, 2008; Lovi & Barr, 2009;
Morgan, 2006), a lack of knowledge, related to limited education and training, was still seen
as a major barrier to providing adequate care to PWSUD, even for specialty providers
(Adams, 2008; Ford, 2010; Ford, Bammer & Becker, 2009; Kelleher & Cotter, 2008; Happell
et al., 2002; Lovi & Barr, 2009; Monks, Topping & Newell, 2012). Some have related this
deficit to a lack of related content in pre-registration education curricula (Harling & Turner,
2012; Howard and Holmshaw, 2010; Lovi & Barr, 2009; Kelleher & Cotter, 2008; Monks et
al., 2012).
There were some consistent weaknesses observed during the review of this literature.
For example, the majority of the studies rely on self-reported data and there is likely and
element of socially-acceptable answering. There is also an overwhelming focus on
abstinence-based treatment for controlled substance use in the survey tools including the
Substance Abuse Attitude Survey which further legitimizes the approach. There were several
studies that focused on a single urban geographic area. The use of individual sites for
research can highlight the political, social, and other influences that are dominant in a
particular area. Addressing this potential is important when conducting research in particular
areas such as in a more rural geography.
In terms of gaps in the literature, there was only one article by Canadian authors that
addressed the experiences of RNs; this article was from Eastern, urban Canada. Rural health
care professionals were underrepresented in the literature. A thorough investigation of

44

nurses’ experiences of caring for PWSUD, the attitudes that nurses hold, and related
organizational factors, will address some of these critical gaps in knowledge and may in turn
promote evidence-based care that can improve health outcomes in this population.
Interpersonal Relationships
Interpersonal relationships emerged as a significant issue in this review of the
literature. Studies included in this section explored the interpersonal challenges faced by
health care professionals in caring for PWSUD. This is important background information
for the investigation of nurses’ experiences caring for PWSUD for comparison with the
results of my study. Five qualitative studies were captured that related to this theme: a
grounded theory study by Monks et al. (2012); a cross sectional study by Ford (2011); a
grounded study by Morgan (2006); a phenomenological study by Lovi and Barr (2009); and a
qualitative study by Spence et al. (2008). These will now be discussed.
In a Grounded Theory study of nurses and clients by Monks et al. (2012), the issue of
dissonance in the care of PWSUD in acute care settings was evaluated. A purposive sample
of 29 RNs was recruited from a single British Hospital. The nurses were recruited with the
aim of gaining the broadest possible sample; they were primarily female (82.8%), between
21-58 years old, had undertaken education ranging from Certificate of Nursing to Masters of
Science, and had four months to 37 years of experience. As is usual in grounded theory, the
data collection and analysis occurred concurrently and the analysis was used to guide further
sampling and explore emerging areas of interest. Additionally, a convenience sample of 12
PWSUD was recruited via direct referrals from nursing staff. In this study, all of the client
participants regularly used more than one type of substance and had a history of injection
heroin use. Furthermore, all of the clients included in this study had been previously been

45

admitted to hospital for substance use-related medical issues. In-depth semi-structured
interviews were undertaken with the participants and the data were analyzed in congruence
with the Grounded Theory approach. NVivo was employed to facilitate data management
and analysis. Rigour was attended to through reflexive journaling and an audit trail.
Through analysis of the interview data, one core category emerged: dissonant care
management/delivery. This core category developed from two subcategories; lack of
knowledge to care, and distrust and detachment (Monks et al., 2012). In this category, both
nurses and clients recognized a problematic relationship that impacted access to appropriate
care. This difficulty in accessing care produced undesirable behaviours in the clients, which
reinforced nurses’ perceptions and attitudes. The relationship was recognized as being related
to a lack of knowledge regarding the care of PWSUD and substance use in general, as well as
being the result of negative attitudes toward the clients and their life choices. The clients had
a lack of confidence in nurses’ abilities to recognize clinical signs and symptoms related to
individual drugs. The lack of knowledge negatively impacted clients’ access to supportive
education and their care in general. The provision of poorer care to PWSUD is not in keeping
with nursing’s values to care without judgment and nurses reconciled this dissonance by
behaving in a detached way to PWSUD (Monks et al., 2012).
The sub-category distrust and detachment emerged from tense relationships between
nurses and substance abusing clients that were conceptualized as being the result of mutual
distrust. Nurses reported feeling disconnected from their clients, spending less time with
PWSUD, and were less likely to really understand and attend to their needs. The reason most
often reported was that managing PWSUD was emotionally draining. Only a few of the nurse
participants reported being able to move beyond the described attitude, to perceive the client,

46

and their needs, as unique. Nurses also described a lack of comfort introducing substance
related issues with their patients, which reinforces the perceived lack of knowledge. From the
client perspective, experiencing nurses’ detachment resulted in frustration related to having
unmet needs, and feeling disrespected. These feelings often led to manipulative or aggressive
behaviours by the PWSUD in an attempt to have needs met. Conversely, the feelings and
behaviours exhibited by PWSUD, at other times, resulted in self or forced discharge and
thus, unmet health care needs (Monks et al., 2012).
The two subcategories identified by Monks et al. (2012) interrelate to one another to
give a more comprehensive picture of dissonant care and how it occurs. One of the themes
that emerge from this article is that of othering; “nurses may seek to reduce their disquiet at
being unable to fulfil their core caring role or engage in emotion work with [PWSUD] needs
by labelling them as difficult, problem and sometimes alien clients” (Monks et al., 2012, p
944). The nurses place PWSUD firmly into the other category and this causes an immediate
disconnect between them. Ultimately, the authors argue that care of a PWSUD is often
complicated and lacks continuity, and this leads to poorer health outcomes for clients. Nurses
who see clients with SUD as difficult or problematic are likely to limit contact and feed into
a cycle of distrust that also results in poorer client outcomes. Education and training are
crucial to interrupt this cycle and improve nurses’ abilities to care for PWSUD.
This study helps to clarify and explain how disconnections in practice may arise. The
findings from the study highlight the importance of the attitudes and viewpoints of the health
care providers in the care of PWSUD and reflect the findings of literature previously
discussed. The findings in the Monks et al. (2012) study were corroborated in a qualitative
study by study Ford (2011), who examined how interpersonal challenges impact nursing care

47

of PWSUD. Ford collected qualitative data simultaneously with quantitative data collected
for a separate paper that looked at nurses’ attitudes toward harm reduction strategies in
treating SUD (Ford, 2010). The Ford (2011) paper analyzed narrative data from 311 nurses
from across the Australian Capital Territory. The narrative data was the product of one open
ended question in which nurses were asked to “describe any factors that impeded their ability
to provide nursing care to clients who use [controlled substances]” (Ford, 2011, p243).
Analysis was facilitated using NVivo. The data were reviewed, coded and then analyzed
thematically. Peer review of the analysis was undertaken by the researchers and three nurses
from the study sample.
An overarching theme relating to “interpersonal challenges in the nursing role” along
with three subthemes were identified; impediments to care, including “violence,
manipulation and irresponsibility” (Ford, 2011, p.243). First, “violence as an impediment to
care” was presented in relation to portrayals of PWSUD as aggressive, angry, and
unpredictable, with nurses indicating that they frequently felt afraid for their safety during
health care interactions with this group (p.243). As a result of this fear, nurses report giving
in to client demands in order to protect themselves and other clients from potential conflicts.
Second Ford (2011) identified “manipulation as an impediment to care” (p.243). In this
theme, the nurses reported feelings of frustration at being manipulated by PWSUD. Nurses
shared their experiences and perceptions in relation to substance seeking behaviours,
including a lack of trust in the veracity of client’s statements and behaviours. These
behaviours caused nurses to have concerns about making client care decisions and to
question clients’ motivation for medication. Finally, the nurses identified irresponsibility as
an impediment to care (Ford, 2011). The nurses demonstrated a belief that clients refused to

48

take responsibility for their own health and social circumstances as a result of their SUD.
Ford commented that this lack of responsibility was perceived to increase the workload for
nurses who then had to manage health issues related to substance use and other socially
undesirable behaviours.
The study by Ford (2011) corroborated the findings by Monks et al. (2012)
suggesting that these interpersonal challenges resulted in a detachment between nurses and
their clients in the form of restricted time and personal engagement. However, Monks et al.
(2012) went one step further to suggest that client behaviours were also related to the
treatment they received from nurses and that it was a cycle of dysfunction whose ultimate
product was poor outcomes not only for the clients but also for the nurses who often felt a
lack of job satisfaction in relation to managing PWSUD. Ford (2011) touches on harm
reduction as a potential method for encouraging engagement in relationships between nurses
and PWSUD. By using harm reduction to guide care, nurses would be able to focus on health
and social well-being without any expectation of cessation of use.
There were some limitations to the Ford (2011) study including that it was a cross
sectional study that only highlighted one moment in time and also that nurses self-selected
whether or not to answer the open ended question on the survey which may have skewed the
results. The strengths were that many nurses identified important challenges in the care of
PWSUD and how they perceive their role in this activity.
Similar findings were identified in Morgan’s (2006) Grounded Theory study of 18
people with SUD (aged 32-60) in acute care settings in a large public urban hospital in
America. The analysis of the study data revealed that interpersonal relations and perceptions
around substance seeking behaviours were seen to impact upon client care. This study

49

focused on the strategies employed by PWSUD for obtaining pain relief and supports the
theory that interpersonal interactions between nurses and PWSUD can have a significant
impact on care and care outcomes for clients. While this study corroborates the findings of
the Morley, Briggs and Chumbley (2015) study presented in the previous section in that the
findings suggested that pain for PWSUD was often poorly managed in the hospital setting,
the Morgan study investigated the interpersonal interactions that impacted PWSUD’s
strategy implementation to gain relief from pain. This study found that past experiences in
gaining or failing to gain adequate pain relief impacted clients’ decision making processes in
subsequent encounters. The decision-making processes were largely based on the
individual’s ability to gauge the attitude of the nurses and then opt for strategies that they
perceived as most likely to assist them in gaining adequate pain management (Morgan,
2006).
In the study by Morgan (2006), four client strategies for obtaining adequate pain
management were identified. First, when PWSUD felt respected they were able to
collaborate with health care providers and this often resulted in adequate management of
pain. Second, when clients were unsuccessful at getting pain relief and still feeling respected,
many PWSUD strategized by “going back to the drawing board” to try and get relief
(Morgan, 2006, p.37). This reflects a level of understanding that some pain relief methods are
not effective for some PWSUD. Clients in this scenario were willing to wait and work with
the care provider to find a solution. Third, when PWSUD felt disrespected, they were more
likely to “challenge the system” as a strategy for gaining relief. Fourth, when still
unsuccessful, PWSUD may turn to true antagonism out of frustration (Morgan, 2006, p.37).

50

Other challenges identified by the client population in Morgan’s (2006) study were a
lack of knowledge regarding pain management and SUD and negative attitudes toward
PWSUD. Through this process, a model was developed that described the process that
PWSUD go through to obtain pain relief. This is in keeping with the author’s research
method of Grounded Theory, where the goal is to develop theory to explain phenomena
(Morgan, 2006). The model was shared with participants during subsequent client interviews
and focus groups with nurses to enhance understanding and ensure that their views were
reflected appropriately (Morgan, 2006).
Another study by Spence et al. (2008) used a qualitative design to examine the
experiences of suicidal men with a history of SUD and frequent presentations to the ED at a
large urban hospital in Toronto. Spence et al. (2008) interviewed clients and ED staff at a
single hospital, employing a maximum variation sampling process. The client participants
were identified by the ED staff and then approached by researchers to gain consent for
inclusion in the study. Twenty five men between the ages of 18 and 25 were recruited. These
men all had SUD as well as other mental illnesses such as clinical syndromes (anxiety and
mood disorders) and personality disorders (Antisocial and Obsessive Compulsive Personality
Disorder). Seventeen staff participants were self-recruited, however no demographic
information was collected. The staff sample consisted of six RNs, five physicians, two crisis
team workers, two security officers and two non-medical staff members (Spence et al., 2008)
An analysis of the study data revealed three major themes. First, reasons for
presenting to the ED; most often the men perceived that they were forced to attend the ED
against their will by care givers, family member, or other community professionals. The men
stated that they found the ED to cause them increased anxiety. This is consistent with Monk

51

et al.’s (2012) supposition that tense interpersonal interactions have a circular effect on
subsequent nurse-client interactions. Spence et al. indicated that nursing staff reported
several attitudes that acted as barriers to care including believing that the men are too
disorganized, and that the men were using the system. The second theme was client
behaviour. Both clients and staff recognized that clients who act out and are disruptive
received care more quickly. Often psychiatric issues were deemed less acute than
physiological issues and this could lead to delays in care in the context of the ED. The final
theme identified was “identification of the repeat visitor and experiences in the ED” (p.343).
The clients identified that being labelled as a frequent flier had detrimental effects on timely
and adequate care. The health care workers also identified the prominence of negative
experiences for this population. Many staff identified feeling pessimistic about the efficacy
of treatment and frustrated by the demands on their time. Many were able to identify the
difficulty in treating the SUD and mental illness and that there was no immediate solution.
Overall, Spence et al. (2008) suggested that given the chronic nature of MH&A
problems, definitive care could not be provided in an emergency setting. However, realistic
goals could be set and achieved. This research sets the stage for more studies that investigate
whether training and systemic changes to client care will impact client outcomes.
Interpersonal challenges have also been seen to lead to significant stigma for
PWSUD. For example, Lovi and Barr (2009) further explored the experience of stigma in a
phenomenological study of Alcohol and Other Drug units (AOD) in Queensland, Australia.
A purposive sample of six nurses (aged 35-58) was interviewed.
Guided by Giorgi’s phenomenological method, the authors analyzed the data and
identified three themes including inappropriate judgment, advocacy and education (Lovi &

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Barr, 2009). Data related to inappropriate judgment reflected the AOD nurses’ identification
of general RN’s as the perpetrators of discriminatory behaviours both inside and outside the
AOD. The interviewees identified advocating for their clients as a very important part of
their jobs. These nurses held very optimistic and permissive attitudes to treatment and relapse
related to SUD. Finally, the nurses identified lack of knowledge as a major contributor to
strained relationships between nurses and PWSUD. They also identified a knowledge deficit
as a barrier to PWSUD accessing appropriate and adequate care for illnesses linked to SUD
(Lovi & Barr, 2009).
Summary. Overall, the review captured five studies that explored interpersonal
relationships between nurses and PWSUD. The evidence so far suggests that stigmatizing
interactions can impact quality of care and that a cyclical relationship exists between nurses
(and other health care professionals) and PWSUD that may impact negatively on client
outcomes. This cycle of distrust by both health care professionals and PWSUD often results
in suboptimal care of PWSUD by nurses, as well behaviour that health care professionals
consider inappropriate or unpleasant. The literature also points to a nursing knowledge deficit
as a contributing factor to the difficult nature of these relationships. It is critical that a
baseline understanding of nurses’ experiences in EDs be investigated in order to help direct
clinical guidelines and educational programs aimed at interrupting this cycle and improving
nurse and client satisfaction with care.
Organizational Factors
The analysis of the literature captured in this review found that organizational factors
are also important when understanding the experiences of health care providers managing
clients with SUD. Four studies were identified and critically appraised as relating to

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organizational factors (Baldacchino, Gilchrist, Flemming, & Bannister, 2010; Ford, Bammer,
& Becker, 2008; Ford, Bammer & Becker, 2009; Koyi et al. 2017). All four studies were
selected for review in detail since they were relatively recent and relevant to the Canadian
context.
In their 2008 article, Ford, Bammer, and Becker sought to examine the association
between nurses’ therapeutic attitudes toward PWSUD and a set of variables identified by the
authors as pertinent to therapeutic attitudes. These variables were developed based on a study
that looked at associations between education, knowledge and client engagement (Ford,
2010). The variables that the authors associated with therapeutic attitudes included personal
characteristics, attitudes to substance use and a number of professional practice variables.
Finally, the authors sought to examine the strategies most likely to be effective in developing
the workforce in relation to caring for PWSUD.
Ford, Bammer and Becker (2008) used information derived from the same survey
used in the Ford (2010) and Ford (2011) articles described previously to investigate how best
to implement workplace changes to elicit changes in nurses’ therapeutic attitudes toward
PWSUD (n=1604). This survey included one variable from the National Drug Strategy
Household Survey, a study that had been used nationwide. In this case, the information of
interest was the not only the nurses therapeutic attitudes and their attitudes toward substance
use but also the nurses’ personal characteristics, including age, sex, education, religious
affiliation and church attendance as well as professional practice factors, such as role
requirements and workplace factors.
The authors used a hierarchical method of multi-variable linear regression analysis
with blocks of variables (personal characteristics, attitudes to substance use, role support,

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substance use and alcohol education, experience with the client groups, and workplace
factors). The dependent variable was therapeutic attitude. They began by establishing a
linkage between therapeutic attitude and workplace/professional practice factors. Other
blocks of variables were tested one at a time in the model. A likelihood ratio test (Irtest x 2)
was used to compare one model with a more restricted model. When the Irtest x2
demonstrated an improved fit in the model (p=0.05) the block of variables was left in the
model. They called their model the Statistical Model of Therapeutic Attitude. Using this
model the authors could determine the impact of changes in the variables. They found that
improvements in therapeutic attitude were most impacted by an increase in role support. Role
support was defined as the availability of other nurses or professionals that the nurse could
access easily to “discuss personal difficulties, clarify professional responsibilities and
formulate the best response to clinical issues” (Ford, Bammer, & Becker, 2009, p.115).
Doubling role support potentiated an increase of 15.8% in therapeutic attitude. The highest
increase in therapeutic attitude (17.8%) was seen with the interaction between high role
support and workplace education.
To further this, in 2009, Ford, Bammer, and Becker worked to explore the impact of
role support and drug and alcohol education in the workplace in greater depth. In the
previous study, the interaction of role support and workplace education included role support,
measured on a 7-point Likert scale, and education, measured in hours from 1-30 or more
working in tandem. Workplace education on its own was not a statistically significant
predictor in the original model (p=0.492) but was significant in the interaction with role
support.

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In this study, Ford et al. (2009) used a regression model to predict the level of
therapeutic attitude with changes to role support and workplace education. For each level of
role support from 1-7, the time for education in hours was increased by five hours. With the
results from these calculations the authors developed a three dimensional model that depicted
impact of role support and education on therapeutic attitude (Ford, 2009).
The results showed that without role support, education has little or no effect on
therapeutic attitude. Education only became effective once there was a moderate level of role
support and this symbiotic relationship continued to grwo from low levels of education
through to high levels of education. These findings were significant because other studies had
suggested that a lack of education was a barrier to the provision of safe care to PWSUD
(Adams, 2008; Ford, 2010; Kelleher, 2007; Happell, Pinikahana & Carta, 2002; Harling &
Turner, 2012; Lovi & Barr, 2009; Monks, Topping & Newell, 2012; Morgan, 2006). The
authors stated that a lack of role support resulted in low confidence in the ability to engage
with and care adequately for PWSUD. Like Monks et al. (2012), Van Boekel et al.(2013) and
Morgan (2006), Ford et al. (2009) suggested that nurses’ low confidence in their abilities
would result in disengagement from the client and that a negative cycle of interactions would
follow. This places some responsibility on the organization to ensure that adequate support
for the role of the nurse in caring for PWSUD is present.
The limitations of these two studies are that they are based on a cross-sectional survey
that was based on self-reporting which does leave some room for socially-acceptable
answering. Furthermore the regression model is hypothetical in nature and has not been
demonstrated in the research exploring the actual practice setting.

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From a different perspective, Baldacchino, Gilchrist, Flemming and Bannister (2010)
undertook a qualitative study of physicians and their prescribing practices for pain control.
Their focus was on clients with non-cancer pain who had a history of SUD. They interviewed
19 individual physicians from a variety of specialties including family medicine, pain and
addictions, as well as held two focus groups, one consisting of four GPs and one with six
specialist Drug Problem Service Physicians in the UK. The findings were significant in that
they identified a bias, particularly by general practitioners, toward under prescribing pain
medication for fear of being manipulated or being seen as enabling those with histories of
SUD. This is very pertinent to my research study because EDs in rural communities are often
staffed by GPs. This study also identified distrust of clients as a primary barrier to adequate
pain control and stigmatization of PWSUD, even those who were no longer suffering with
SUD and subsequent potential for poorer pain management. The authors also identified poor
pain management as a potential indicator of clients returning to the use of nonprescription
and other controlled substances to help manage the pain. This theme echoes the article by
Morgan (2006), in relation to the cyclical pattern of stigma and poor pain management and
clients’ use of strategies to gain adequate pain relief.
This article was included under the organizational theme as it demonstrates how
pervasive the stigmatization of PWSUD can be and how it might negatively inform emergent
care of this population. Caring for a population that has been stigmatized by distrust and
suspicion is very difficult and must be well supported through not only front-line practice but
also through policy and protocol. Change must be widespread and include management,
policy makers, physicians, nurses and other members of the health care team both in the
hospital setting and in the community.

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In order to ensure the literature review was as comprehensive as possible, it was
updated to capture any remaining literature up to 2017. This resulted in the addition of one
further article that looked at the effectiveness of an educational intervention in second year
medical students. Koyi et al. (2017) conducted a study in the United States aimed at
determining whether an educational intervention was successful at improving the attitudes of
second year medical student towards PWSUD. The medical students completed a pre and
post survey that consisted of questions that fit into three categories, treatment optimism or
confidence in intervention, moralism, or stereotyping. Once the students had completed the
pre course survey, they participated in a 15 hour, three-day workshop where they worked in
small groups to demonstrate and practice their clinical skills associated with caring for
PWSUD. The students had the opportunity to learn motivational interviewing techniques,
interviews PWSUD, and work through cases of caring for PWSUD.
The data was analyzed using a Wilcoxon signed rank test that compare the pre and
post course survey responses to determine if the medical student’s attitudes toward PWSUD
had improved after the educational intervention. The data comparison was executed using W
statistic and p value where p < 0.05. The size of the effect was calculated using Cohen’s d
statistic. All the analysis was completed using Stata 13.1 software (Koyi et. al., 2017).
The results of this study showed that there was an overall positive change in the
medical students’ attitudes towards PWSUD following the three-day workshop. At the
individual level, the students demonstrated more positive beliefs about the difference that
they could make in the lives of PWSUD (Koyi et al., 2017). Some of the limitations of this
study were that the effect was not measured over time, as all post course surveys were
completed within one month of course completion, and that the results were from a single

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university in the United States. One of the strengths of this study was conducted over two
consecutive classes of second year medical students. This study provides information about
the impact that educational interventions can have on the attitudes of health care providers
towards PWSUD.
Summary. Overall, four articles were reviewed that highlighted the importance of
organizational factors, including role support for nurses and workplace education. Together
these articles begin to demonstrate how difficult a task it will be to change the culture of care
for people experiencing SUD, but how critical it will be to examine this issue on an
organizational and systemic level. It must begin at the organizational level with a focus on
providing adequate and judgment free treatment with clear guidelines for all health care
professionals.
Overall Summary
A number of gaps and limitations were consistently seen in the literature, including
the small scale of many projects and the lack of diversity in settings as many are single centre
projects in large urban hospitals. However, a number of consistent messages were seen in the
literature overall. First, attitudes and perceptions of PWSUD are generally negative and this
has been shown to impact upon the delivery of care and client outcomes. Second, clients feel
stigmatized when accessing emergency treatment and are likely to receive substandard
treatment in the context of hostile client-provider relationships. Third, organizational factors
can perpetuate these stigmatized views. Finally, education and training in a well-supported
role, along with regular contact with the client group, was seen to improve outcomes. Further
research is needed to explore the experiences of ED nurses, particularly within the context of
rural emergency care. Understanding these challenges in the context of limited health care

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services, vast geography and diverse and disperse human populations further extends the
existing literature and provides contextualized insights that are useful for those delivering
and planning health care services in rural settings.
To address these gaps, this study explored the experiences of RNs as they care for
PWSUD in emergency room settings. The following section will provide an overview of the
methods for this study.

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Chapter Three: Methods
This chapter will describe the research methods employed for this study. However,
initially I will describe how the method was selected and the philosophical foundations of the
study.
Study Design
A qualitative approach was selected to answer the question: what are registered
nurses’ experiences of caring for people with substance use disorders in an emergency
department setting? Qualitative research approaches inquiry from a perspective that
recognizes the dynamic nature of reality. This approach allows increased value to be placed
on other sources of knowing and knowledge outside of traditional empiricism and seeks to
explore a given phenomenon within the natural context (Munhall, 1988). Qualitative inquiry
is an alternative methodology to the positivist paradigm and can generate critical insights into
client and health care outcomes (Morse, 1994).
As a naturalistic method, qualitative research aims to study a phenomenon in its
context through collection and analysis of data that is more subjective than objective and
often, narrative in nature (Loiselle & Profetto-McGrath, 2011; Morse, 1994)). Qualitative
research can bring a depth of understanding and richness of description of the human
experience to the body of nursing knowledge that is not present in quantitative research. As
such, qualitative research can bring a complementary perspective to the body of nursing
knowledge and uncover tacit knowledge and taken for granted insights that have important
clinical implications (Magilvy & Thomas, 2009). This unique clinical perspective can be
extremely useful for clinicians in terms of direct practice but also for decision and policy
makers so that they can make decisions that will most benefit clients and those providing

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direct care to them. As highlighted in the review of the literature, little is known about
nurses’ experiences and understanding of caring for PWSUD in the ED setting. Utilizing a
qualitative approach can be important in situations whereby little is known and can
contribute to the existing body of literature (Sandelowski, 2000).
Selecting a Methodology for Qualitative Inquiry
In order to address the research question a qualitative approach was selected and
within this, a descriptive methodology was then selected as it was consistent with the aims
and scope of the research. Through this early exploratory process, several qualitative
methodologies were considered for this study including interpretive phenomenology and
qualitative description. This process of contrasting and critically exploring different
methodological approaches was important since the methodology strategically informs
research design and the subsequent decision making around the methods, questions,
processes, and outcomes (Schultz & Cobb-Stevens, 2004).
During the early part of my graduate studies, I considered phenomenology as a
potential methodology for this research due to its focus on the lived experience.
Phenomenology is considered both a philosophy and methodology that focuses on the human
experience and the meaning embedded in the lived experience (Parsons, 2010). Interpretive
phenomenology is employed by researchers who are interested in discovering the meaning i n
everyday life and investigate the experiences of individuals through the analysis and
interpretation of narratives, while descriptive phenomenology is focused on describing the
participants’ experiences as they see them (Lopez & Willis, 2004; Parsons, 2010). In
phenomenology, the data consists of a narrative account that is reflective of the lived
experiences of the subject or interviewee (Lopez & Willis, 2004). In the case of this study,

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descriptive rather than interpretive phenomenology was considered. The primary focus of
descriptive phenomenology is to have a result where the participant’s voice is heard and his
or her experience is described faithfully (Lopez & Willis, 2004). Interpretive Phenomenology
is concerned with the essence of a particular phenomenon as a lived experience, emphasizing
the commonalities that exist among them (Lopez & Willis, 2004). While this method places
focus on the voice of the participant, its main intent is on the essence or composite of the
experience resulting in this method not being selected. As a novice researcher, I felt I had not
yet developed the depth of theoretical knowledge of the phenomenological methodology and
philosophical underpinnings required for this type of research. In addition, I wanted to
undertake research that would be relevant and easily translatable to the clinical practice
setting. Therefore, a qualitative descriptive approach was selected as being the best fit for the
research. Furthermore, given that this is a newer area of interest the essence of the experience
was not my goal. Rather, I sought to understand the experiences and perspectives from a
variety of RNs in the ED setting.
Qualitative description, like all forms of qualitative inquiry, is a naturalistic form of
inquiry or methodological approach (Sandelowski, 2000; Sandelowski, 2010). This approach
has been widely used in health care disciplines. Qualitative description has been used to
study the decision making behaviours of charge nurses, stroke care, and patient engagement
in primary care to create a rich description of the phenomena (Sheridan et al., 2015; Sorensen
et al., 2014; Wilson, Talsma, & Martyn). Qualitative description is most useful for studies
that develop or refine interventions, needs assessments, or where the researcher is focusing
on the experiences of clients, families, and professionals as they interact with one another or
within the health care system (Neergaard, Olesen, Andersen, & Sondergaard, 2009).

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Qualitative description allows for a variety of theoretical perspectives and like descriptive
phenomenology, places value on the voice of the participant, encouraging the researcher to
stay close to the data. Because little information is currently available about the experiences
of RNs who work with PWSUD in the ED, qualitative description enabled me to investigate
and describe this phenomenon. Consistent with a qualitative approach, a description of the
philosophical foundations of the study have been included in the following section.
Philosophical Foundations
Exploration of the epistemic, ontological and methodological underpinnings of any
research study is an important means of identifying the position of the researcher within the
study. It allows the researcher to have greater understanding of the way decisions are made
and thus adds to the dependability, credibility, transferability and transparency of the study
(Guba and Lincoln, 1994; Houghton, Casey, Shaw, & Murphy, 2013; Morse, 2015). The
following sections will discuss my ontology, epistemology, and situation of self, regarding
this work, followed by a section on the methods used for this inquiry.
Ontology and Epistemology
Transparency around philosophical assumptions is essential in qualitative research as
it provides context for the reader about the starting point of the research project and can assist
readers in determining the trustworthiness of a study (Leung, 2015; Mesel, 2013).
Philosophical assumptions are often communicated to a reader using descriptions of the
author’s ontological and epistemological perspectives. Ontology describes how one views the
nature of reality, while epistemology refers to how knowledge is acquired (Leung, 2015).
Both are important philosophical aspects of research as the way reality is viewed and
explored can have a significant influence on the research process. The following section will

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identify my ontological views and epistemological perspectives and will examine situation of
self as it relates to the research paradigm and process.
Ontology. Ontology describes the nature of reality (Mesel, 2013). My perspective
most closely adheres with Critical Theory in that I do believe that reality exists. However, I
also believe that any description of that reality is socially constructed by the describer. Thus,
I believe in an understanding of reality as a social construction that is historically situated in
a social context and is dependent on the individual experiences of the narrator. Furthermore,
critical positions also explore issues of power and dominance, particularly those that are
more tacit in nature. Critical theory is complementary to health research focused on
stigmatized populations due to the focus on identification of social inequities, and the
purpose of using knowledge gained to mediate or eliminate health inequities (MosquedaDiaz, Vilchez-Barbosa, Valenzuela-Suazo, & Sanhueza-Alvarado, 2014).
Epistemology. Epistemology is best described as the “relationship between the
knower (inquirer) and what is known (knowable)” (Guba, 1994, p.18). Here again, my
perspective aligns with Critical Theory (Habermas, 1992). I believe that dialogue and
language influence thought and action. I believe that every interaction we have influences our
thinking. I believe that while the participants shared their stories with me, there were aspects
of the conversation that I influenced, and aspects that the interviewee influenced ultimately
resulting in the creation of something that was reflective of us both. Similar to Habermas
(1992), I also believe that knowledge is dynamic, in part because what we know about what
can be known is historically situated and socially contextualized.

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Given this perspective, knowledge is a creation rather than something that is
discovered to be in existence independently of the inquirer. As such, it is important to
provide a detailed description of my own experiences as they related to this project.
Situation of Self
Since I am a RN with a history of working in the ED and as an RN educator, the
following section will address my own positioning and provide some background to enhance
the transparency of the research.
Role as RN. My professional background and the associated clinical experiences
have impacted the way that I approached and understood this work. I came to be interested in
this work because I had cared for and observed PWSUD in the ED and felt that their care was
often inadequate. On occasion, I witnessed clients with SUD who were unable to gain access
to appropriate and timely care or situations where clients with SUD were not followed up. I
felt this injustice deeply and wanted to do something that could make a difference. It was
these experiences that led me to apply to graduate school and to undertake this research. In
doing this, I hoped to increase my understanding about nurses’ experiences and some of the
factors that impact upon the care of PWSUD in the ED, and to be in a position to use this
knowledge to improve practice.
With respect to the research, my clinical background as an RN working in the ED
provided some benefits. Principally, I had some insider or shared knowledge of the ED and
was able to understand and relate to the participants and their experiences, largely because I
was familiar with the environment, language and the mechanisms of care delivery.
Throughout the process of collecting data, I felt I could relate to their stories and the context
in which they were practicing. Likewise, having this shared understanding and professional

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background was similarly beneficial as I believe it made participants more comfortable when
being open about their experiences and perspectives. As such, many of the interviews were
lengthy and very detailed. Overall, this shared professional background enabled me to
identify and follow up on nuances that might have otherwise been overlooked in a researcher
not familiar with the nursing practice and setting.
While my familiarity with the setting was beneficial, there were similarly, some
potential drawbacks that I had to consider. First, having worked in this area, I had firsthand
experience seeing a range of perspectives that nurses held with respect to SUD and PWSUD.
I also knew that I had some assumptions entering into this work. My assumptions included
that many nurses had negative beliefs and attitudes toward PWSUD and that these were due
to their personal values and backgrounds. I was careful to examine and watch for these
assumptions during the data collection and analysis. Through ongoing reflexive practice, I
was able to challenge these presuppositions and flush out situations where I was unsure about
my position or potential influence on the research. There were occasions where I felt that my
own assumptions were a potential influence on how I asked questions, how I approached
topics with the participants, and how I engaged in the analysis of the data. One example of
this occurred during data collection when I was struck by a reoccurring approach to caring
for PWSUD as described by the participants. I noticed that many of the nurses I interviewed
discussed how treating PWSUD with respect was integral in relationship building and
developing a therapeutic relationship. I also noted that I felt a surprised to hear this with the
frequency that I did and had to really look at my own established ideas about nurses who care
for PWSUD. I explored these feelings in my reflexive journal.

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“I am noticing again and again that I am hearing about how ‘treating people with
respect’ is one of the most important parts of helping PWSUD in an ED. I was
surprised to hear this, even though I feel this way myself. I think I have to be careful
to be very open to what I am hearing. I also need to be aware that I have bias toward
at least some ED nurses that caused me to feel surprised. I do feel now a bit
embarrassed about it but going forward I will be on the lookout for it. I understand
what they mean about respect because you have to be able to develop a relationship
with clients so quickly and because people have to be able to trust you as the nurse,
demonstrating respect is coming up again and again as a way to help develop that
therapeutic and trusting relationship very quickly. It is also identified again and again
that demonstrating a lack of respect is problematic in terms of building an effective
partnership….For the most part, the nurses who selected to be involved in this project
seem to have a fairly positive view of PWSUD in terms of acceptance…this is
interesting and I think it would be interesting to see if PWSUD’s experiences echoed
those of the nurses of if self-perception and the perception of others differs
significantly….This really is turning out to be a very complex issue.
I also had the opportunity to spend time with an experienced academic supervisor to check
my analysis, test out ideas and be challenged around these assumptions.
Role as an educator. Further to this, I have a role in educating student nurses at the
undergraduate level and so have an in-depth understanding of the pre-registration education
that nurses receive at the university where I work. I recognize that there are some deficits
related to learning about SUD and caring for PWSUD within the program and that I am part
of the system that fails to adequately prepare nurses with respect to this issue.

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Over the course of the research, I had some internal conflict around being part of the
problem. For example, I was aware that I had worked in an environment that has failed
clients and in education that has contributed to and potentially perpetuated this issue. This
made me especially aware of seeking opportunities to include SUD and PWSUD in more
areas of my teaching as well as ensuring that I took steps to try and eliminate stigma and role
model effective and appropriate attitudes, knowledge, and strategies to help meet the needs
of PWSUD in tertiary care. Again, reflexivity provided an important mechanism through
which to identify and critically examine these assumptions. The following sections will
describe the methods selected for this project that were used to create a greater understanding
of nurses’ experiences caring for PWSUD in the ED.
Method
Qualitative description methods share some similarities with many other qualitative
methods such as increasing understanding of a given context, as well as individual
experience of a phenomenon. Essentially, this approach enables researchers to explore things
that may be overlooked if utilizing quantitative methods (Colorafi & Evans, 2016). In a
qualitative descriptive approach, phenomena are explored through the transcripts of
participant interviews or through examination of other data sources. Immersion in the
transcript data allows the researcher to identify patterns and understand the events as they are
experienced by the participant within the context of their experiences (Neergaard et al.,
2009). The expectation of qualitative description is that it will produce a comprehensive
summary of events, rather than a highly interpretive or theoretical text (Sandelowski, 2000).
Given that the goal is a rich description of the subject of interest to the researcher, the
researcher stays very close to the data resulting in lower inference descriptions that will

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increase the opportunity for agreement among researchers (Colorafi & Evans, 2016). The
goal is to ensure descriptive validity, by ensuring accuracy in reporting of events, and
interpretive validity, by ensuring that the meaning conveyed by the participants is reported by
the investigator (Neergaard, et al., 2009; Sandelowski, 2000). This approach has been
employed to study a wide variety of events from clinical nursing interventions to particular
phenomena within the health field (Breau & Rheaume, 2017; Chafe, 2017).
This is not to say that qualitative description is devoid of interpretation as all
description and analysis includes interpretation. Sandelowski (2000) stressed that the
investigators’ “perceptions, inclinations, sensitivities and sensibilities” (pp.335) will
inevitably impact what is recorded and how it is reported. This makes awareness of the
researcher’s theoretical leanings a crucial step when undertaking qualitative description
(Neergaard et al., 2009). Reflexive activities are as important in this methodology as any
other to ensure that the findings in the study reflect the participants’ interpretations rather
than the researcher’s.
Researchers undertaking a study using qualitative description do not need to adhere to
a single theoretical point of view (Sandelowski, 2000). Aspects of other methodologies may
colour qualitative description. For example, constant comparison may be employed in
qualitative description, but no theory would be generated through the process (Sandelowski,
2000). Qualitative description was selected for this study for its flexibility related to
philosophical underpinning, sample selection, data analysis and for its focus on providing a
rich description of the experiences of an otherwise under-researched phenomenon.

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Sample
Descriptive qualitative methods allow for in-depth analysis of data which investigate the
meaning in the ED nurses’ experiences caring for PWSUD. To answer the question: what are
the experiences of RNs caring for people with SUD in an ED setting?, a purposive sample of
RNs working in both rural and urban communities who care for people presenting to the ED
with issues related to substance use were interviewed (Milne & Oberle, 2005). I sought to
capture a broad range of nurses from a number of different settings. In addition, I attempted
to seek variety in the age and gender of participants where possible. A range of ages was
represented in the research (25-57years). However, despite considerable efforts to recruit
both male and female nurses in the research, all of the participants identified as female. The
participants were recruited from three sites in the NHA; UHNBC in Prince George, BC;
Prince Rupert Regional Hospital in Prince Rupert, BC; and Fort Saint John Hospital in Fort
Saint John, BC. These sites were selected for their location, one in each of the HSDA in the
NHA. Within this region, Prince Rupert and Fort Saint John each have high incidences of
hospitalizations attributed to substance use (University of Victoria, 2016). The sample size
was determined according to the principles of theoretical saturation, where saturation is
reached when no new key insights or major themes arise with analysis of new data; in
qualitative description saturation is not necessarily a requirement; however, I was able to
reach this point in analysis (Bowen, 2008; Sandelowski, 1995). 13 participants were recruited
and theoretical saturation was reached during the analysis.
Recruitment. Prospective participants were recruited via emails distributed through
the NHA intranet and were sent to RNs working part time or full time in the ED at the
hospitals identified above. To minimize any potential conflicts, emails including the letter of

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information and participant information sheet (Appendix D) were provided to the site
managers for distribution. Managers distributed the letter of invitation and the participant
information sheets to RNs working at the sites as invitations to participate in the study.
Connections were made with ED managers across the NHA region to assist in the
distribution of emails. Follow-up emails were sent by the researcher to the managers at three
and six weeks after the initial email requesting that the original invitation be resent to the
RNs until the desired sample was achieved. A third set of email invitations to participate
were required to increase the number of participants from nine to 13.
Inclusion criteria. The goal of recruitment was to have a sample that included a
diverse range of participant RNs that represented a variety of perspectives including gender,
geographic location, years of experience and age. Participation in the study required that
participants be RNs whose primary positions were in one of the EDs in Prince George, Prince
Rupert, or Fort Saint John. This included both full time and part time nurses, as well as
participants who were casual nurses but worked the equivalent of 0.5 FTE or more.
Participants were all able to communicate effectively in English and were willing and able to
provide informed consent. The participant’s demographic information was recorded
separately from the data analysis to protect confidentiality (Appendix E).
Exclusion criteria. RNs working casual positions in EDs that worked less than the
equivalent of a 0.5 Full Time Equivalent (FTE) were not eligible for inclusion in this sample
due to the inconsistent work schedules and the possibility of limited contact with PWSUD.
RNs holding leadership or managerial positions were also excluded, since the focus of the
study was the experience of ED nurses providing direct care for PWSUD in the ED context.

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Participants in this study were explicitly informed of the voluntary nature of their
participation and that they may terminate their involvement at any time without fear of
consequence. Participants were asked to provide their signature on a consent form outlining
their involvement and the intended use of the data gathered prior to our first meeting and
again for verbal consent prior to commencing the interview. The verbal consent was captured
on the audio recordings. They were also informed that their permission to use the transcripts
could be rescinded at any time. Prior to providing consent, prospective participants were
provided with a detailed description of what inclusion in the study entailed as well as any
risks and benefits that they might incur as a participant (Appendix D). Participants were
encouraged to ask questions or seek further clarification as needed. While this was
considered a low risk study, participants were informed in the information sheet and prior to
the interview that they may potentially feel uncomfortable with some questions or topics and
were informed that they were able to terminate the interview at any time or refuse to answer
any questions they did not feel comfortable with. In the event that a participant may have felt
upset, the participants were also made aware that resources were available for counseling or
mental health support upon request.
Confidentiality was maintained throughout the research process by ensuring that
transcripts were anonymized, being given only an assigned number and region. Coded
transcripts were available only to the researcher and supervisor and were otherwise stored in
an encrypted computer file. While confidentiality of the data was maintained, participants
were made aware that due to the smaller settings where the research was undertaken, it is
possible that anonymity may not be completely guaranteed. In the event that situations were
to arise where there was concern about anonymity, I had planned to either not use the data or

73

review this with the participant in question. This scenario did not arise during data collection.
In congruence with the conditions of the Research Ethics Board (REB) approval, the
transcripts will be securely held for five years and then destroyed.
Data Collection and Analysis
Data was analyzed concurrently with collection, and was organized thematically. For
clarity, data collection and analysis will be presented separately.
Data Collection. Qualitative interviews are the conversational process of knowing; a
knowledge producing social interaction (Kvale & Brinkmann, 2009). Interviews can differ in
form across disciplines in terms of their purpose and goals (Kvale & Brinkmann, 2009).
However, all interviews consist of an interaction based on language between two or more
individuals (Brinkman, 2013). A semi-structured interview approach was used to collect the
data. The use of a semi-structured interview process allowed the participants to offer the
information they deemed important and helped to ensure that their voice was present in the
study (Milne & Oberle, 2005).
A well-developed interview schedule will enable the researcher to increase the
opportunities for new knowledge discovery (Corbin & Strauss, 2015) and provides a vital
point of preparation for the novice researcher. Questions must be developed sensitively and
not be worded in a way that is confusing or influences the participants’ answers; they must be
free of language concerned with the researchers’ preconceptions or biases (Rubin & Rubin,
2012). This can be done by using a broadly scoping question to begin and narrowing the field
of inquiry based on the participants’ responses.
During the early stages of the research process, an interview schedule was developed
and piloted to ensure that the questions elicited relevant information and were easily

74

understandable. The pilot interviews were executed with three nursing colleagues recruited
from the home institution of the research. The interview schedule was then adapted according
to the feedback from the pilot sessions; this included refining the language of some of the
questions, ensuring that these were free of jargon that might impede comprehension, and
considering the addition of some prompt questions to elicit detailed responses. An interview
schedule used in the research has been provided (Appendix F). As the research continued,
this research schedule was expanded to reflect interesting themes arising from the
preliminary analysis. For example, in early interviews, participants frequently identified that
a lack of training and education impacted their experiences. As a result, I sought to explore
this in greater detail and asked subsequent participants specifically about their preregistration education and the education they had specifically in the ED.
I conducted all of the interviews between August and December of 2016. Prior to
commencing an interview, participants were asked to read and signed the informed consent.
The interviews were conducted by telephone or in person based on the preference of the
participant and geographic location. Sessions ranged in length from approximately 12
minutes to 80 minutes. Interviews occurred at mutually agreed upon times that offered
flexibility and ensured the confidentiality of the participants. Sessions were digitally recorded
with permission from the participants and then transcribed verbatim by a transcriptionist who
signed a confidentiality agreement. The purpose of digitally recording and transcribing the
interviews was to ensure that the data was accurately recorded and that the nuances, such as
specific vocal tones or silences, could also be captured and included in the analysis. Field
notes, documenting ongoing interpretations or non-verbal communication for interviews held
in-person, were also collected to contribute to the analysis.

75

In addition to the interview data, basic demographic information was collected to
define the study sample, this includes age, gender, years in practice, type of employment (full
or part time), education level and time spent working in EDs (Appendix E). This information
was collected to help in understanding whether there were similarities between groups with
different amounts of life and work experience.
Data Analysis. A qualitative descriptive approach was used to analyze the
experiences of nurses’ who care for PWSUD and analysis was organized thematically (Braun
& Clarke, 2006). This method of analysis is appropriate as it focuses on descriptions of the
manifest and latent meanings, intentions, consequences and context of the transcripts rather
than looking for hidden meaning (Elo & Kynga, 2008; Vaismoardi, Turunen, & Bondas,
2013). These analysis approaches employ a lower level of interpretation than other data
analysis approaches, such as grounded theory or hermeneutic phenomenology, but result in a
thick description where the participant voices are evident. Descriptive analysis is “well -suited
to analyze the multifaceted, important, and sensitive phenomena of nursing” (Vaismoradi et
al., 2013 p.403). This approach fits well with increasing understanding of the experiences of
frontline nursing. Talking about substance use and PWSUD, can elicit some intense feelings
and reactions from people so remaining close to the participants’ descriptions of their
experiences will provide a rich and representative description. A rich description is created
through the development of critical themes that emerge from the analysis, using concept
categories as vehicles for the description (Elo & Kynga, 2008).
An inductive approach to analysis was undertaken in this study. This was consistent
with the underpinning methodological approach and the topic in hand: as the experiences of
nurses caring for PWSUD in an ED setting had not been studied in depth, therefore there was

76

little in the way of theory to use for comparison. During data analysis, the first step was to
become immersed in the data. To gain this immersion, I read and re-read the transcripts
repeatedly as a means of gaining familiarity with the data. Once familiar and comfortable
with the data, the next step was to identify codes. Codes represent important ideas and
responses that provide insight into the research question (Graneheim & Lundman, 2004). The
codes were then arranged and grouped into higher order categories or clusters (Elo & Kynga,
2008; Viasmoradi, et al., 2016). While categories and concepts were developed based on
prevalence, prevalence of themes was decided based on relevance to the research question
rather than purely the number of times it appeared (Braun & Clarke, 2006). The broader
codes and categories were utilized to create themes, resulting in a general and rich
description of the nurses’ experiences (Vaismoradi et al., 2016). Data analysis in this study
resulted in three primary themes.
Regular review with the lead supervisor allowed for peer checking and supported
supervision until consensus in the interpretation and analysis of the data (Elo & Kynga,
2008). This was then presented to the wider supervisory team for discussion. This process of
checking and support helped to ensure that nuances were explored and that the analysis
process was trustworthy, authentic, and credible (Lambert & Lambert, 2012; Lincoln &
Guba, 1985).

77


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78

Trustworthiness
Trustworthiness is typically used in qualitative research as a key concept to help
describe and understand the quality and rigour of a study, as opposed to the term validity,
that is more in keeping with the values of quantitative research (Morse, 2015).
Trustworthiness consists of confirmability, dependability, transferability and credibility
(Lincoln & Guba, 1985). It is in applying these concepts to the research process, in addition
to ongoing reflexive practice, that trustworthiness for this research was addressed.
In the context of qualitative inquiry, dependability addresses whether or not the result
will be consistent over time. While this is potentially the most difficult to confirm, it can be
addressed using external audits. In my study dependability was addressed by having my
supervisors examine the process and the written product (Billups, 2014; Morse, 2015).
Meetings with my supervisors occurred at regular intervals throughout the research process
from preconception of the study through completion. Agreement among the team was
reached regarding methods, execution, analysis and presentation of the findings thus
providing evidence of dependability.
Transferability addresses whether the results of a study are applicable in similar
settings (Billups, 2014). In qualitative research, thick description is used to allow the reader
to make determinations about the transferability (Morse, 2015). The more robust the
transcripts, field notes and audit trail, the better able one is to make this determination. For
this study, the description of the nurses’ experiences was provided in detail. Likewise, a
reflexive journal was kept to provide evidence of the decision making processes and the
thought processes involved in the analysis of the data.

79

When confirmability is assessed, the accuracy of the findings is evaluated (Billups,
2014). Audit trails and reflexivity are the most common ways to address confirmability
(Billups, 2014; Morse, 2015). I kept a reflexive journal throughout the process and this was
also how I kept track of my decision making. Keeping a reflexive journal allowed me to
practice self-reflection and ensure that attention was paid to my own influence on the
process. It also allowed me to track the challenges I encountered and my thought process as I
moved through this research study. Through the reflexive journal I was able to explore my
own feelings about the research process, the things I discovered about myself through the
interviews, and my experience of the analysis process. This was considered central to the
analysis process in order to expressly identify my own situation within the research. For
example, after a particularly challenging interview I wrote:
I just did an interview that was really very challenging. The person being
interviewed expressed some perspective about SUD that I found really difficult to
hear and some thoughts about nursing that I found difficult to accept. I think as I
move forward into analysis, I will have to be really careful that I look at the words
used and the things that were said while being very aware of how I felt during the
interview. I need to be conscious of looking past my own feelings and developing a
way to think about what was said from a variety of perspectives. What could be
behind the things she said? Is it bias? Or discrimination? Or is there another
explanation?
Allowing myself to explore these thoughts not only provided me with a sense of caution or
attention to my own perspectives, but also challenged me to consider how peoples’ beliefs
and values influence an individual’s experience.

80

The reflexive journal also served to track my decision making and the rationale
behind the selection of themes to discuss. I utilized drawings to assist me as I organized my
codes thematically. While the end result differed from the initial drawings, they were useful
in working out the connections and the meaning present across the interview transcripts.
Additionally, at various points in the analysis process, the decisions made were documented
using photographs, drawing, and tables to record the process (Figure 1).
Finally, credibility must be addressed as a part of determining rigour in qualitative
studies. Credibility refers to the internal validity of the study. Credibility of a study can be
reinforced in a number of ways including persistent observation, triangulation negative case
analysis, referential adequacy and member checks (Morse, 2015). In this study the credibility
was demonstrated using member checks and referential adequacy. The members were able to
look over their transcripts to ensure the message they intended was conveyed. However, only
three of the participants returned their transcripts with any comments and those comments
were primarily editing comments. Comparisons in the literature were made to the original
texts where no corrections or comments were returned to me by the participant and with the
corrected version in the cases where comments were returned.
The following chapter will describe the findings and provide a description of the
participants’ experiences of caring for PWSUD in an ED setting.

81

Chapter Four: Findings
To understand the experiences of RNs caring for PWSUD in an ED setting, semi
structured interviews were undertaken with 13 RNs from three different EDs in the Northern
Health Authority region. The RNs were all female, aged between 25 to 57 years (mean 42.7
years), and had between 8 months and 30 years (mean 13.1 years) of experience in the ED.
Demographic information for the participants is offered in table 1. The interviews were
conducted either by telephone or in person and the verbatim transcripts were analyzed
descriptively and thematically. From analysis of these data, 50 codes were identified initially.
Subsequently, these codes were collapsed into six subthemes that identify and explore the
experiences of RNs of caring for people with SUD in the ED setting. These subthemes were
grouped into three major themes which are discussed in the following sections. The themes
are: PWSUD in the ED, where the participants describe their roles and the role of the ED as
it pertains to the care of PWSUD; Organizational Barriers where the participants’ education
and perceptions of resources and supports are discussed and; Attitudes and Beliefs where the
personal beliefs of the participants are discussed as they related to the care of PWSUD. These
will now be presented (Figure 2).
Theme One: PWSUD in the ED
During the interviews, the participants discussed at length the process and experience
of caring for PWSUD in the ED setting. In particular, nurse participants shared diverse
beliefs, perspectives and values about their perceived role in caring for this population.

82

Table 1
Participant Demographic Information
Interviewee

Gender

Age (Years)

Place of
employment

Years as an
RN

Years in ED

Level of
education

1.

Female

55-65

Site 2

35

27

Diploma

2.

Female

45-55

Site 3

30

30

Diploma

3.

Female

25-35

Site 2

8

7

Degree

4.

Female

55-65

Site 2

35

9

Degree

5.

Female

25-35

Site 1

4

<1

Degree

6.

Female

35-45

Site 2

23

21

Degree

7.

Female

35-45

Site 2

19

10

Diploma

8.

Female

25-35

Site 2

2

1.5

Degree

9.

Female

35-45

Site 2

22

12

Degree

10.

Female

45-55

Site 1

33

27

Degree

11.

Female

45-55

Site 1

26

14

Degree

12.

Female

25-35

Site 1

3

4

Degree

13.

Female

35-45

Site 1

22

7

Degree

83


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Theme One:
PWSUD in the
ED

Theme Two:
Organizational
Barriers to Care

Beliefs about
the Role of the
ED and ED RN

Wanting to do
the Right Thing

Preparedness

Resources and
Supports

Challenges of
providing care

Formal and
informal
preparation

Barriers to
education

Knowledge
deficits and
consequences

Theme Three:
Beliefs and
Attitudes

Personal Beliefs
and Attitudes

Patient and
Provider
Interface

Interpersonal
interactions


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84

Participants described their strong belief that the primary function of the ED is crisis
intervention. For the majority of the participants, this meant that “the first role [of the nurse]
is to make sure they’re [PWSUD] medically stable and getting …their ABC’s…taken care
of…just to make sure that they’re surviving and kind of leaving in a better state than they
came in medically” (Participant Five). When addressing the care of PWSUD specifically, a
couple of participants identified that at times the immediate needs are critical and that ED
nurses “certainly … need to support them [PWSUD] through their immediate crisis”
(Participant Six). Overall, the majority of the respondents commented on their belief that the
focus of ED care is the physiological health of the client rather than the mental health needs
of the client.
Some participants agreed that while crisis intervention is a primary role of the ED,
nurses must also attend to client needs once the crisis has passed. For instance, one of the
participants described, “the kind of very nice thing about critical care nursing is that you’re
dealing with people not only in their crisis but also in the aftermath” (Participant Four).
Likewise, Participant 13 explained that care begins with
more [with] symptomatic care at first, right, and then later on when they’re [PWSUD]
fully awake, they stay with us and we kind of like, do our therapeutic thing and then
ask them if they want some referrals…so we kind of just liaise with them on the
things that need help [with].
Conversely, some participants viewed crisis intervention as the necessary aspect of ED care
and identified difficulty in providing the aftercare because “it’s so easy for us to just give the
support with the drugs and everything else but to give the emotional and the teaching and all
of that, it’s just impossible in the emergency situation” (Participant One). Meanwhile,

85

another participant admitted, “I do not do as much with that because I am not a mental health
nurse, but that plays in my mind with discharge” (Participant Two).
Challenges of Providing Care. In this context, time emerged as an important
concept for the ED nurses when discussing their experiences of caring for PWSUD. The
participants recognized psychological care as an essential part of the care of PWSUD.
However, many identified that there was inadequate time to provide this kind of care within
the ED setting. Several participants stated that they often lacked the time to provide high
quality care in this domain. One participant remarked that “emergencies are really a fastpaced place and two hours to sit and talk to someone in one of my areas and stretcher blows
down my whole system” (Participant Two). Several nurses commented on being unable to
provide the psychological, emotional, spiritual, and social care that people with SUD require
due to time constraints and expressed frustration at not being able to meet the needs of the
patients. Participant Three shared:
we, as nurses, may not necessarily have the time to sit down with somebody and go
over options in terms of, ‘oh hey you want to go to a recovery program or you want to
access detox? …We may not necessarily have the time to sit down and provide
information or support or, just to talk to somebody about what’s going on with them.
Overall, participants described feeling frustrated that they were unable to meet the broader
needs of this population; that they felt they were not providing the necessary care or follow
up that they believed these patients needed and that there simply is not time in their workday
to manage all the needs of these complex patients.
Other participants expressed frustration when PWSUD presented repeatedly to the
ED with non-urgent issues. Several participants believed that the ED was being misused by

86

some PWSUD as a place to “come and get hydrated and you’re good to go” (Participant 10).
This sentiment was echoed by another nurse who identified that at times PWSUD are
“brought back to the ED because they are intoxicated on the street, because they are laying
down, because they haven’t eaten, because they’ve fallen down. Because they’ve been
fighting and become a public nuisance…[because there is] really no other place to take them”
(Participant Two). While still another felt “these problems can be managed out of the
Emergency room or it can be prevented. If we have like steady follow-up and support you
know from outside the hospital setting (Participant 10). Several other participants described
non-urgent use of the ED in less value laden terms for example, “PWSUD often come in for
minor issues like a laceration or a chest cold” (Participant Three).
The participants differed in their emotional response to the non-urgent use of the ED
by PWSUD. A couple of participants voiced their frustrations at having to manage PWSUD
in the ED because “it takes a lot of time away from other patients when it’s busy”
(Participant 10). Another participant made similar comments about caring for PWSUD and
using time that could be spent with people with other, more mainstream issues. Other
examples include Participant Two who was particularly vehement in expressing, “except for
Emerg, they have no place else to go,…our department, taking away someone else’s time,
they don’t need us.” This participant also expressed feeling frustration at the social issues
experienced by PWSUD she admitted, “I find it really difficult, How is that [the social
issues] everybody in this department’s problem…I just have a problem when it takes away
from other people”. In contrast, one participant voiced frustration but from a different
perspective, stating that she felt sorry that nursing staff had to leave the PWSUD to go and
manage a patient in a critical situation. Participant Four described that:

87

often times in the ED, you end up getting pulled into more…the more life or death
situations so you could be right on the brink of being able to have a wholesome
discussion with [PWSUD] about…even the Narcan kits now that we’re able to give
out…and behold a cardiac arrest comes in and you get pulled into that other situation.
Several participants acknowledged that the ED is an entry point for some PWSUD to access
health care and that EDs play an important role in insuring that people who do not have or
are unable to access, for whatever reason, health care in other ways are still able to get the
help they need. In total, seven of the participants identified that often PWSUD present to the
ED because feel they have nowhere else to go. Participant Three expressed her belief that the
ED is an “easy access point for them [PWSUD] and a safe place…I feel like if that’s what
our department can provide for these people, that safe place for them to come with any
question or concern, then that should be our role”. Likewise, two other participants thought
that the hospital might represent a safe place to be that would protect them from the stigma of
the general population. For example, one nurse thought that for some PWSUD “it’s probably
just because the hospital is their refuge” (Participant Eight). Building on this, Participant
Four asserted:
Most folks are uncomfortable going to a walk in clinic when they’re, when they’ve
got active drugs or alcohol on board. People tell me at triage that they don’t go to the
walk in clinic because they have to stand in line up or they get laughed at so they
come to the ED to receive their care instead.
These statements refer to the stigma that some PWSUD suffer and must manage as part of
accessing the health care system.
Several of the participants explained that the ED is not an ideal setting to provide

88

excellent care to PWSUD post crisis or for non-urgent health care needs. This resulted in
clients whose needs were not being met within the ED. When their needs were being not met,
several participants described PWSUD choosing to leave the department without a discharge
plan or any follow up. A nurse working in one of the smaller sites admitted:
if we have somebody who’s a trauma or a code or whatever, then because you only
have two staff on nights, those people [PWSUD] end up getting neglected or not seen
too often. We’ve had them rip out their IV’s and run away and by the time you get
back to the bed they’re gone, no one’s seen them (Participant 12).
Similar issues occurred in the larger, more urban site. For example, Participant Eight
described that once stable, PWSUD
get put into the hallway or under one of our counters [ledge] and then we care for
them that way so that they have a safe place to stay before they go to detox…we tend
to lose people because who wants to sleep in the hallway?
Wanting to do the Right Thing.
During the interviews, all of the participants talked about their feelings about how
care was provided in the ED setting. There were discrepancies in what some of the
participants described as helping. Some believed that helping meant cessation of use while
others believed helping to be meeting the expressed needs of the client including cessation of
or the reduction of harms related to substance use.
Some participants thought that the interventions provided in the ED were sometimes
detrimental to PWSUD, principally because they did not explicitly discourage substance use.
For example, one participant commented “that we’re just encouraging them to continue on
with their addiction when we should be…stopping them from going and doing it again”

89

(Participant 10). Participant One’s response supported this perspective, she explained how
the treatment might encourage return visits, “I don’t think we’re helping by giving her a
banana bag, you know, multivitamins and the thiamine [because] every time she’ll be here”
(Participant 11). This participant thought that by relieving the discomfort of intoxication and
withdrawal, the PWSUD would simply come back for more treatment the next time they
used substances.
One of the participants shared her belief that the provision of care should include
mandatory medical withdrawal. This participant suggested there should be “somewhere
where [PWSUD] have to go mandatory for seven days or 10 days or however long it takes to
get off the alcohol so that you can have a different perspective” (Participant Two). This
participant believed that a sober person might make decisions that resulted in abstinence. It is
important to note that not all the participants shared this belief and that this participant had
several perspectives on providing care that were not simply limited to mandatory
detoxification.
Several participants spoke about assisting PWSUD to access the help they needed as
part of their role as a nurse. An example was provided during a discussion about the role that
nurses have in caring for PWSUD which she described as” advocating to getting them to feel
better, like physically as well as trying to get them the help they need” (Participant 12). Many
of the participants identified the need to develop strong therapeutic relationships. This was
explained as a way to create a safe space where PWSUD felt comfortable asking to have their
needs met. One participant described it as conscientiously building “that bond so that they
[PWSUD] can access the help if they need it” (Participant Eight).
A couple of participants indicated that part of building the bond was to offer help.

90

One participant commented that “every time they come, not to give up,…to say can we do
anything for you. Not to force it on them. Can we do anything for you?” (Participant Six).
Another participant placed a great deal of value on the offer of referrals. She explained:
every time I do it [offer referrals], I never feel it’s a waste. It is the only way he can
get out of this situation and every time he comes, I’ll always say the same thing, you
know man, your life is going nowhere, you’re young and you’re bright and you need
to look at that and you need to go to alcohol and addiction counselling and they can
get you set up and it’s never, never, never a waste. I don’t care if a guy goes back to
rehab 42 times, maybe that 43 is all it’s going to take to change and make a
difference (Participant Two).
Overall, the participants indicated a desire to help PWSUD through the immediate crises and
in accessing ongoing care. Although the desire to help was present throughout the interview
transcripts, at times, the participants expressed feeling that intervention was futile for an
array of reasons including the lack of availability and appropriateness of ongoing care, and
limited patient uptake of treatment. At the same time, several participants also described
feeling hopeful each and every time a PWSUD expressed the desire to enter into recovery.
One participant described the role of an ED nurse as a role that’s “very fraught with wanting
to provide good care but then there’s all these restrictions on what you can do and people
deal with that in different ways” (Participant Five). Frequently, within a single section of the
conversation, participants would describe the desire to help and some level of frustration at
not being able to help the way they would like. This pattern was repeated in many of the
interviews. Some participants explained that at times, they feel frustrated by the frequency
with which a PWSUD accesses the ED. For example, Participant 10 explained

91

I mean it’s frustrating, if you’re doing something and you’re helping somebody, it’s
not that you want a thankyou or whatever, but if you can see oh yay okay that guy
was there and now he’s serious about trying to get help. But, then you see them come
back time after time again like nothing’s changed. Why?
Another participant offered a similar experience of feeling frustrated and frightened on some
level with PWSUD who return to the ED on a regular basis with intoxication and overdose.
She described her feelings by saying “I wouldn’t be surprised if he’s been in this month again
and again. I don’t know what we can do for him...I find that’s the most frustrating. The thing
is, the next time somebody may not start CPR” (Participant Two). While some participants
expressed frustration with the system or with the patient, some nurses expressed frustration
with themselves and their perceived inability to enact change. Participant 12 explained
feeling
Frustration, like with yourself because you can’t fix a problem, like if somebody has
just sort of a medical problem and you know how to fix it, and you fix it, but there’s
no like easy fix, right. You just, sort of, think I did everything right and it still didn’t,
kind of… well they’re still drinking and whatnot.
The beliefs and attitudes of the participants about PWSUD and their core professional beliefs
and attitudes at times are at odds. Crisis intervention was identified as the primary role of the
ED. This belief resulted from the focus of the ED specific education and training on
physiological care. Regardless of this focus, all of the participants stated a desire to make a
difference for the PWSUD that they came across. However, many of the participants found it
difficult to reconcile the realities of providing care to PWSUD in the ED in today’s climate
with their professional values.

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Many of the participants, particularly those from the smaller centres, stated that many
community resources also have rules, Participant 11 described a resource for PWSUD that
can only be accessed if they are sober “we refer them to [the resource] if they are sober,
cause the [the resource] will not accept them if they are drunk”. These participants were
concerned about the continuation of a cycle that they viewed as detrimental to the client. The
participants who described concern about the care provided in the ED to PWSUD were
concerned about the continuation of a cycle that they viewed as detrimental to the client.
Theme Two: Organizational Barriers to Care
Organizational support emerged as a key finding in the analysis of the interview data.
Participants frequently identified that the availability and presence of organizational supports
and resources had a major impact upon their perceived ability to care for PWSUD. Through
the analysis, two subthemes were developed to describe the impacts of organizational
support, these are: preparedness, and resources and supports.
Preparedness
A lack of preparedness was a key theme that emerged repeatedly during data
collection and was seen by the participants as being a barrier to providing appropriate care to
PWSUD. During the interviews, the participants described their education and training and
how it served to support them in providing care to PWSUD. Overall, the participants
perceived that they received little or no formal education with respect to caring for PWSUD,
with much of their learning occurring through informal education processes, such as peer
learning, experience in practice and self-directed study. The participants often described that
they experienced barriers when attempting to gain access to formal education. It was this lack
of formal education and training that led to a perceived knowledge deficit related to

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providing care to PWSUD and some of the participants identified negative consequences for
both nurse and patients resulting from the lack of preparedness.
Formal and informal preparation. During the interviews, the participants
discussed the formal education they had received including, pre-registration training,
specialty RN training courses, local education, and training session and workshops. The
majority of the participants identified that formal education, specifically geared toward
caring for PWSUD, was limited or often absent from both their pre-registration education
and their ED specialty education. When the participants were asked about their education and
training in the interviews with respect to caring for PWSUD, many of the participants
responded initially with humour, going on to describe that educational opportunities were
limited and for the most part inadequate. While reflecting on their ED specialty training,
several participants felt that the focus on caring for PWSUD was equally limited. One
participant described her formal education about SUD “uh nothing (laughs)” (Participant 11).
This was supported by another participant who explained “we had like a three-month long
training session and we didn’t even touch on substance abuse” (Participant 12). Instead, the
content of the ED training was orientated to the assessment and stabilization of clients with
life threatening conditions. While this might include a person with severe mental health
disturbances, or a PWSUD who has overdosed, many of the participants recognized that the
courses were “very medical focused” (Participant Seven) and were frequently limited to
addressing the management of trauma or the unstable acute care patient. One participant
described her training as being focused on “A [airway], B [breathing], C [circulation], is A,
B, C clear and then to go to next, is the patient safe?”(Participant 11). Likewise, another
participant described her ED specialty training as consisting of “ACLS [Advanced Cardiac

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Life Support], BLS [Basic Life Support], TNCC [Trauma Nurses Core Course], PALS
[Pediatric Advanced Life Support] or anything that would certify [her] to be able to work in
Emerg” (Participant 13). These courses focus almost exclusively on physiological care of a
patient who is at risk of imminent death.
In contrast, a few participants recalled a receiving a small mental health component
within the ED specialty training, although education specific to SUD was not included
substantially for nurses providing emergency care. Participant Eight identified that “the
Emerg training I took, it was an in-house course, and I don’t remember anything really
focusing on the needs of substance abuse patients. There was a mental health component and
I think a small little paragraph on substance abuse”. Similarly, another participant described
the education she thought RNs new to the ED were receiving at the time of the interview.
I think now they spend one shift with the Psychiatric Liaison Nurse (PLN), four
hours with the PLN nurse I think, as part of their orientation and other than that,
there’s not a lot directly for addictions and services. So basically it’s just teach them
how to manage I guess the aggressive patient and the addicted patient and turn
them the other way when they’re going to vomit and wear a gown when you’re
helping them to the bathroom so they don’t pee down your leg, that sort of
stuff (Participant Seven).
Fewer participants spoke about their pre-registration education than their ED specialty
education, however when they did, the participants recalled their pre-registration education
had addressed substance use, but that it had been limited to a small section within a larger
module on mental health. This was identified as being inadequate preparation to provide care

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to PWSUD because it did not provide sufficient information particularly given how common
it is to see SUD in practice. For example, one participant recalled
I feel like in training, we’re given…a chapter on mental health disorders and here’s
a little paragraph on substance abuse or use concerns and these are what drugs people
commonly use, these are what they do and that’s really it” (Participant Three).
All but one participant believed that further education and training would be
beneficial as a way to enhance preparedness for practice. Overwhelmingly, the participants
demonstrated an interest in gaining more knowledge and skills to enable them to provide
evidence informed care and to increase their confidence in their nursing care. For example,
participant Seven stated a desire to have more in-house training sessions. She stated:
I’d like to see somebody in the drug and addictions field that specializes in this area
to come in with helpful hints and tips and give us a really good list of the resources
available and which ones are appropriate for which patients so it’s clearer than what it
is now.
Following an analysis of the interview data, it was clear that none of the participants
identified that they had received targeted education that focused on the care or management
of PWSUD.
While the participants stated a wish for more training and education, they also
emphasized the important role that experiential learning has in the development of nurses
from novice nurses to more expert nurses. Informal education was described, by the
participants, as experiential learning, mentorship and self-directed study. For instance, one
participant said: “I mean we do learn a lot as you go…you’re always continually learning
things within the department” (Participant One).

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The majority of the participants identified that learning as you go is of importance,
with ten participants describing that their clinical experiences helped them to gain skills
related to caring for PWSUD. These participants described experiential learning as an
iterative process that each nurse engages in based on his or her own pre-existing knowledge
and skills, and the ongoing experiences with PWSUD. One process described by a couple of
the participants was that of trial and error, where nurses experimented with strategies and
learned from reflecting on the outcomes. For example, one noted that
it’s trial and error. … I’m still going through it, and they [new nurses to the ED] are
going through their own trial and error….And sometimes they’re going to find
success in their approach and sometimes they’re not and they’ll tweak it for the next
time and it seems like it’s just a repeat (Participant Seven).
Similarly, several other participants discussed the patterning of behaviour as a way to plan
strategies for managing the care of PWSUD. Participant Nine described her experiences of
learning on the job as
Day-to-day, like you learn how to deal with it as they come in and it’s just based
from your experience, oh, I’ve seen this kind of escalation before, I’ve seen this, you
just let them be or your just do this. So it’s just based on your experience.
A third participant described her perspective of experiential learning; that of learning from
the patients. This highlights the value of contact with PWSUD in the preparation necessary to
become proficient in caring for PWSUD. Participant Six explained, “I’ve learned a lot from
myself, from walking down the wrong road (laughs). I mean to bail myself out. I think the
patients themselves have taught me a lot”.

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In addition to experiential learning and formal education, the participants also
identified that mentors were important in assisting nurses to make sense of experiences in a
way that improved their practice. The majority of the participants discussed the relationship
between nurses new to the ED and mentorship rather than mentorship as an ongoing
relationship. A few participants described this kind of learning as “on the job training,
learning from your co-workers and figuring out what works and what doesn’t work”
(Participant Seven) and that “the best thing we can do with new people is mentor them with
somebody who’s been around a while” (Participant Six). One participant commented on the
importance of having strong mentorship and that the reality is that that is not always
available on the unit. She said
You can hope you have some good mentors on at the time when you’re dealing with a
difficult patient and how to approach that…If you don’t have good supports, then
you’re just sort of feeling your way in the dark and just the best you can (Participant
Seven).
Several participants further explained that learning is also based on an individual’s
motivation to learn independently about a given topic. For example, one participant said “if
we want training, we read online, train ourselves, do it ourselves” (Participant 10). Similarly,
another participant described “I have my own personal drive to find out what’s up to date and
stuff” (Participant Six). This demonstrates a desire to stay current in their practice, but also
suggests that nurses may be more likely to develop knowledge in areas where they have
interest. One participant commented that increasing knowledge about a topic will be reflected
in the practice of the individual. She said “if you have the inclination, you’ll learn and… kind
of your practice will reflect that” (Participant Five).

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Overall, the participants explained that while experiential learning and self-directed
study are necessary, increased access to formal education and mentoring were needed to
optimize the nursing care of PWSUD.
Barriers to education. Several barriers to education were identified by the
participants during the interviews. The barriers that the participants identified included both
the availability of education opportunities, as well as the ability to take advantage of
opportunities when they do arise. Some participants highlighted that there was a lack of
availability of education focused on the care of PWSUD in the context of the underfunding
of MH&A as a whole. While other participants, discussed their difficulty or perceived
difficulty, in accessing education even when it was available.
Several participants perceived that there were barriers to education focused on the
care of PWSUD as a direct consequence of underfunding of MH&A services on an
organizational level. The participants often inferred that many areas of health care are
underfunded, with MH&A being perceived to be more overlooked or marginalized than other
areas. For example, one participant spoke about the allocation of funding in health care:
“health care in general doesn’t have enough funding, but mental health and substance abuse
doesn’t have near enough attention” (Participant Eight). Another participant stated “supports
in general around people with mental health and addiction issues are inadequate. …mental
health is so underfunded in our community; I don’t know what to say except that it’s
completely inadequate.
For others, barriers to education were perceived to be the result of local health
human resource challenges and financial cuts. For example, Participant 13 explained that, in
the smaller centres, sustaining funding for education in the ED was problematic due to the

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lack of access to learning opportunities “when I came here…there was an educator. They
took it because of budget, budget money”. This view was shared by most of the participants
from the smaller sites. Overall, these participants highlighted that inadequate and unsustained
investment in education within their work setting in relation to PWSUD left them feeling
unprepared when caring for this vulnerable population.
In addition to a lack of dedicated resources, several participants identified a lack of
time during working hours to access the education, whether this means during their shifts or
being paid to attend outside of their normal working hours. This barrier was attributed to the
increased workload and expectations for care while on shift and the lack of available funding
for extra hours, often overtime hours, for education. Participant 1 observed “it’s hard to get
people on board to do anything extra other than their shifts” and “how do you incorporate
that [education] into your work day? Which is darn near impossible these days” (Participant
One). Likewise, another participant commented that the onus is on the individual nurse to
seek out information and to learn independently when they have less busy times on night
shifts rather than specific training during work hours or paid hours of training. This
participant noted that her sources of information are sometimes less academic and more
media based. She said:
during the nighttime when we don’t have anything to do right, so it’s just like go and
browse [the internet]…like an article that you can read also as well about these
things, but not much. Sometimes I can see just the article on TV or something and go
okay, this is the thing, ya (Participant 10).
Knowledge deficits and consequences. During the interviews, the majority of the
participants identified that they perceived their knowledge base to be weak in some areas

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when thinking about caring for a PWSUD. Some believed that they themselves had a
knowledge deficit concerning illicit controlled substances, while others perceived that there
was a knowledge deficit amongst the ED nurses within their site more generally. Of those
that did identify knowledge deficits, several of these also identified that this could give rise to
negative impacts for both the ED nurse and PWSUD who access care in the ED.
One example, as identified by the participants was centred on a lack of awareness of
the different drugs being consumed in their communities and their effects. One participant
described this barrier, she explained:
there’s an education piece that I think there’s a huge lack of right now in the Emerg
department in terms of illicit substances because people don’t really know what those
are and what the expected reactions are, so they don’t know what the unexpected
reactions are to those … there should be some education on some of the more popular
recreational drugs…I’ve seen that over and over where people don’t know what the
drug is, they don’t know what is normal, what isn’t normal and.. it takes time to look
that stuff up and then, I just think that something like hey, these are the drugs that
you’ll see in Emerg that are illicit and what do they present as and what were the
concerns with them? (Participant 12).
This deficit in knowledge was viewed by some to be a barrier to educating the patient about
the use of drugs and the prevention of adverse reactions. For example, the participants were
concerned about preventing drug overdoses and about supporting patients to prevent this. For
one of the participants, the need to have greater knowledge about substances and their effects
was critical to being able to support and educate patients better. This ED nurse explains the
need to know

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“about substance[s], the drugs that patients use, what are the things? What are the
possible symptoms that if they take too much, what is the management you know?
And then kind of like giving an education to the patient at the end of treatment, like
when they’re discharged” (Participant 13)
In addition to the knowledge of the actual substances and physiological effects, many of the
participants felt that they also lacked preparedness when attempting to manage the
psychosocial needs or address the ongoing needs of PWSUD. The majority of the
participants talked about how addiction is embedded within a complex range of
psychological, social and economic factors. In the interviews, they highlighted that patients
frequently experience a myriad of needs that extend physiological aspects of care. The
participants discussed the challenge of providing this kind of complex care in the ED. One
participant explained that nurses in the ED are “being asked to be social workers in a large
part and that’s not something we’ve been trained for, it’s not something we have time for
(Participant Five).
Several of the participants described consequences for both the nurse and the client
resulting from a lack of preparedness. Some participants identified fear as one of the
consequences for nurses. Fear of approaching the issue of substance use with clients and fear
of more in depth assessments that might reveal issues they do not have the skills to manage.
One nurse stated that some nurses thought it “better just to not address - here’s your IV fluids
and bye bye, let’s not actually talk about what’s going on for you because we don’t, we’re
not trained on how to deal with that” (Participant Three). Similarly, another commented that
ED nurses “give them their fluids and … carry on with [their] other, medical patients that
need our attention” (Participant 10). The participants identified that the physiological care of

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the patient is the focus in the ED and that those nurses who are less well prepared to care for
PWSUD, are less likely to address the broader social and psychological issues in the context
of the ED.
Two participants also thought that nurses new to the ED might have fear directed at
PWSUD due to their sometimes, unpredictable nature. She stated that, “at the back of their
mind, they’re scared on how they are going to deal with these clients…because it’s really
kind of scary” (Participant Nine). Another participant described fear in the nurses new to the
ED by stating “it’s all so nurse dependent [individuals], on their background…some are
totally scared out of their minds at these kind of people” (Participant 12). The participants
highlighted that the consequences of this kind of fear are that nurses might either avoid the
person, or the issue resulting in suboptimal care for the client and poor client outcomes.
Resources and Supports
During the interviews, the participants identified that there were a lack of supports
and resources present in the ED to help meet the needs of the PWSUD. These included time
to attend to the needs and resources within and supports outside the hospital.
The analysis of the data revealed that the nurses desired to see the needs of PWSUD
met, however they often lacked sufficient time to do so as a result of high patient acuity and
workload. As a result, they rely on the supports including social work and PLN within the
ED and the community-based resources outside of the ED. All those interviewed stated that
the social workers and PLN were invaluable members of the team who assisted in providing
care to PWSUD. The participants noted that these interdisciplinary team members helped
address housing needs, financial needs in the case of social worker and initial psychiatric
assessments and interviews as well as referrals to psychiatry and to community MH&A

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resources (where available) in the case of PLNs. For example, participants identified that
social workers provided vital supports for financial supports, housing and relevant
community and health care programs.
However, nurses located in the smaller study sites were less satisfied with the
availability of supports in comparison to those based in the larger regional centre. One
participant from the larger centre noted “we have other services in the hospital like detox
which we can attempt to get our folks into and I know those are all unique services that are
available only in the big city” (Participant Four). This nurse also identified that a social
worker dedicated to the ED is available in the larger centre for a minimum of 12 hours per
day. Conversely, some of the participants from the smaller sites were frustrated that there
was only one social work role to service the entire hospital, the Aboriginal Liaison Worker
“who will always help, even though they’re not First Nations, she kind of like helps them
out” (Participant 13). There were no other social workers at this site, and access to social
work services was limited to when the social worker was on site. This resulted in other
disciplines taking on some of the social work role. This was evident in a statement by
Participant Five; she stated:
Mental Health is being kind of thrown into the discharge planner, social worker role
and it’s not really exactly their job, do you know what I mean? It’s like part of their
job but like the amount that they’re doing just, it’s far more than they’re supposed to
be.
Conversely, a nurse from the other smaller regional site observed that “I have two good
social workers [in the hospital], one for [First Nation populations] and one not. And I will
activate them almost every day, three or four times a day” (Participant Two). Participant Five

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stated a desire to have to social worker role expanded because “more social work…would
definitely take off a lot of the pressure”.
Nurses from the larger regional centre appeared to have greater access to social work
services than nurses from the rural centres. One participant stated that “if you come in on
weekends, we only have one social worker in the whole hospital. But if you come in on the
weekdays, then we have a social worker just for Emerg” (Participant Nine). Participant Eight
demonstrated the importance of the social worker to ensuring good discharge planning for
PWSUD by saying:
I think it’s a really important role for us to connect them with social work and
community supports that will help them but that’s not always done. I think it’s done a
lot, like it’s done, like most of the nurses I work with try hard to do that and we a lot
of times rely on social workers for that.
This is seen as such an important service that Participant Eight went on to say that social
work is “there every day until 8:00 at night and if they’re not [there], I’ll try to keep them
[the PWSUD] in the hallway until the social worker comes in the morning.” The provision of
accessible social work support appeared to be a key support identified by the participants and
was seen as being critical to providing a high standard of care for PWSUD.
Participants also saw the PLN as an important resource and member of the team that
cares for a PWSUD. The majority of the participants closely linked mental health services
and services for PWSUD in their discussions particularly around the availability of resources.
They often cited PLNs as key supports for PWSUD. For example, Participant 12 said “We do
have two Psychiatric Liaison Nurses, cause more often than not it’s a combination of mental
health problems and substance abuse”. Likewise, another participant identified that the ED

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has a “psych nurse, for mental health concerns if that’s a component that has to do with their
substance issues” (Participant Three).
All five of the nurses from two smaller regional sites stated that the PLN role was
new within the months before the interviews and one participant stated that they had relied
on their psychiatric unit nurses prior to this role. Participant 12 said “we have Mental Health
and Addictions that mostly work upstairs [on the psychiatric unit] but they’ll usually come
around in the morning on weekdays and check and see if anybody is left over from the
night”.
While the majority of the participants identified that there were some resources and
supports, the participants made clear that there was a desire to have more hours of the day
and weekend shifts covered by social workers and PLNs. While many commented that social
workers and PLNs are available during weekday and daytime hours, they are more difficult
to access evenings and weekends, a key time where PWSUD may access emergency
services. The participants identified that caring for PWSUD is made easier and more
appropriate by including the right members of the interdisciplinary team. Participant Four, a
nurse based in the larger centre discussed at length the challenges she faced when providing
care, stating that “24 hour social work would be wonderful and I think 24 hour Psych Liaison
Nurse would be wonderful”, while a nurse working in a smaller site identified that “having
around the clock support…would be helpful because it’s usually the dead of night when they
[PWSUD] come in (Participant 10).
Throughout the interviews, the majority of the participants described how they
perceived supports outside the hospital to be lacking or inadequate. For these participants, a
lack of community supports was a challenge when caring for PWSUD. Participants who

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commented on the community resources expressed their perception that the lack of ongoing
support outside of the hospital was the result of insufficient available resources, their own
knowledge deficits about the function of available resources, and organizational barriers.
During the interviews, several of the participants stated their frustration about the lack
of resources available to meet the needs of PWSUD in the ED. One of the nurses working in
a smaller regional centre stated, “it’s just like this huge gap in services that people need that
aren’t being provided and then the access is very sketchy in a lot of other areas” (Participant
13). Other services designed to help people meet the larger social determinants of health,
such as mental health and addictions counseling, shelter beds and harm reduction based
services, were also identified as being overstretched or unavailable.
The participants interviewed identified that there are supports outside the hospital
setting that can assist in the ongoing post-hospital care of PWSUD. The most commonly
mentioned resource was an inpatient withdrawal unit, sometimes coined detox. Participants
in the largest regional centre were more likely to identify the detox unit itself as an important
resource for PWSUD who are interested in abstinence, while those in the smaller regional
settings were more likely to identify that specialized supports such as detox were absent.
Despite an awareness of resources, the participants stated that they perceived the availability
of inpatient withdrawal services in the larger regional centre as being poor, with all of the
nurses from that site identifying that beds were frequently unavailable making this resource
inadequate to meet the needs of PWSUD presenting to the ED. Two nurses from the larger
regional site spoke about how well the inpatient withdrawal unit is able to serve the need of
PWSUD. One nurse described, “we serve a lot of people, so what we have doesn’t meet our
demands” (Participant Eight). Another nurse described a similar situation explaining that the

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inpatient withdrawal unit “is a support when they have a bed available” (Participant Six).
Nurses from the smaller regional sites were more likely to discuss their desire to have a
closer option for people in withdrawal. For example, one participant stated “I’d love to have
[an inpatient withdrawal unit” in our area, I think the closest [is] too far” (Participant Two).
Similarly, a participant from another smaller regional site described that if people wish to
cease substance use and desire medical withdrawal they have to “send them out to [the larger
regional centre] it would be kind of nice to have one here” (Participant 13). This participant
identified that at times, the distance to an in-patient withdrawal unit, is a barrier stating
“since we are so far…its really kind of hard to get them [PWSUD] on board for their
treatment, for detox” (Participant 13). The majority of the participants commented that the
lack of sufficient resources resulted in patients with poor discharge plans or poor follow-up
plans post discharge. The nurses acknowledged this as a source of frustration as they saw the
lack of ongoing post hospital care as a primary reason that individual patients present
frequently to the ED. One nurse described that the smaller regional hospital she worked at
deals with [people from surrounding communities sometimes] far flung communities
and … there’s not many resources in those communities and so they come to us and
we have a little bit more, but then we often send them back to the same situation that
provokes that problem in the same place, right. So it’s like you really see the cycle in
a way that’s hard to deal with because you’re like, yeah, you’re just a small piece in a
big machine and the big machine isn’t very responsive (Participant Five).
Several nurses stated that they worried about what was next for the patient upon
discharge from the ED. They expressed concern for the patients upon discharge. For example
Participant Two said “it’s all good for me to say you’re discharged, but to what?” while

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another explained that the “discharge piece is always fraught with uncertainty” (Participant
Five).
In addition to availability, three participants described at length that a knowledge
deficit regarding the function of each of the community resources available to PWSUD acted
as a barrier to directing people to the most appropriate care. One nurse described “we have a
card with a bunch of numbers for addiction services. There’s a variety of numbers that they
can call to connect when they leave the ED and those tend to be the other supports outside of
the ED” (Participant Seven). Similarly, another nurse from the larger centre described that
she knew little about the available supports explaining:
I find that social workers know a lot more about the programs available…and I can
never remember which one does what, but we have a file thing of the cares and I’m
just like give them to them [PWSUD] and [say]call them (Participant Eight).
The participants described the difficulties they experience directing PWSUD to the most
appropriate resource when they are uncertain of the roles of the other programs. In one
instance a participant admitted “it’s really hard when you don’t know what each service
offers and if they’re going to be a good fit for the patient that you’re dealing with”
(Participant Seven). Furthermore, a couple of participants were able to speak about some
resources but also identified not knowing all of the resources available to PWSUD within
their regions, for example, “I don’t really know what else is in the region available to be
honest” (Participant Three).
Finally, the nurses identified a lack of support from the health care system. Several
nurses commented on a perceived lack of funding and interest in improving and expanding
education and services related to MH&A. One notable exception to this is the newly

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implemented naloxone program; where nurses are being trained to assist people with SUD to
learn to administer naloxone in the community and then supplying them with a naloxone kit
upon discharge. Several of the participants identified that this is in response to the increase in
overdose deaths related to fentanyl that BC has seen over the last two years (British
Columbia Coroners Service, 2017). All but one of the nurses commented on the
implementation of the program, a program that seeks to support the rapid management of
drug overdose. Two nurses described their belief that management had little interest in
change, one stated:
from my perspective, the management from the hospital has done nothing to improve
the state of mental health and addictions in the 10 years that I’ve been there and you
get a lot of eye rolling, you get a lot of sighing, occasionally you’ll find a manager
that says that’s a great idea but nobody is willing to pick it up and roll with it and try.
…The answers were always we have no money for that (Participant Eight).
The previously mentioned barriers to providing excellence in care to PWSUD caused
frustration among the nurses because they see people returning to the ED repeatedly for
similar issues or issues related to their SUD. The nurses described that at times they were
unable to provide adequate care and then felt poorly as a result. They worried when people
left the ED without a concrete plan, and felt disappointed for clients when they were unable
to provide services that both patients and nurses felt were timely. This appeared to result in
cognitive dissonance between the care that nurses want to provide (empirically proficient as
well as holistically sensitive) and the care that they were able to provide given the identified
barriers.

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Theme Three: Beliefs and Attitudes
While training and education influence how care is provided, so too will an individual
nurse’s life and professional experiences. During the interviews, the majority of the
participants discussed their experiences of caring for PWSUD, the following section
describes the nurses’ beliefs and attitudes about caring for PWSUD in an ED setting that
arose during the interviews and how the participants believed their attitudes and beliefs
influence their day to day experiences. In the first section, I chose two participants’ stories
from the interviews to exemplify two very different perspectives; one of tolerance and
acceptance and one of no tolerance for SUD. The more general attitudes and beliefs about
PWSUD, as demonstrated by the participants, are provided in the second section. The third
section explores how the participants demonstrated the desire to provide the best care
possible to PWSUD regardless of their beliefs or attitudes.
Personal Beliefs and Attitudes
During the interviews, many of the participants described their own experiences and
beliefs around SUDs candidly. Two nurses described explicitly the way in which their own
specific personal experiences had influenced their approach to PWSUD in the ED. They
provided examples that demonstrated two extremes of how those experiences have
influenced their practice regarding PWSUD. For example, Participant Two commented about
her experiences with a close family member:
He came to live with me for two years after that [rehabilitation] as his sole guardian.
And in my house with my kids and stuff. So I went down there to just get some prep,
what should I do, what shouldn’t I do? What’s the bottom line? I need a bottom line
of never do this or that. Because we want him to be successful and he obviously

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stayed longer in order to be successful this time. It was his second or third, maybe
fourth time, I’m not sure and each time we’re going to try to make it as successful as
it comes to come out. And one of it was removing him from the …area and starting
new and so moving him [home] and starting new.
She then described how this experience had affected her practice by decreasing her tolerance
for substance use and associated behaviours. This participant’s family member had
experienced success with treatment for SUD and the participant demonstrated a great deal of
hope related to cessation of use for those suffering from SUD. She stated:
I lived it with my brother and eventually with driving him away and saying you can’t
come around, you can’t be part of my life with your substances, not even for a
moment, or my children’s life. And that reminds me of just being that hard line
offering the help but not supporting his habit,
The participants’ opinions around this could be seen as being consistent with a more
abstinence based approach to treating PWSUD. While this perspective is described here
using a personal story, other participants’ perspectives echoed the same point of view and
appear in the next section.
A second participant (Participant Three) also described experiences with PWSUD in
her personal life. She spoke about a close friend who had struggled with SUD all throughout
his teenage years and into his adult life. This participant’s description of how her practice
reflected this personal experience differed from the previous participant because she stated
that she gained increased empathy towards PWSUD. Her approach was less vested in
cessation of use and more focused on seeing the person in front of her in that moment.

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I have personal experience...my best childhood friend has huge substance abuse
issues. He’s been constantly in and out of treatment his whole life so, whenever a
patient comes in with that sort of a history, I try and put it into perspective and think
of, okay, if this person were my best friend, how would I treat them or how would
they want me to treat them. And, you try and not forget the fact that whatever is
going on with their substance issues, that at the end of the day they are still a person.
The extremes described in the previous paragraph, one nurse who developed an intolerance
for substance use and the other who had increased empathy for PWSUD, were reinforced
throughout the interviews where participants’ attitudes and beliefs about the causes of SUD
were evident. This binary view of SUD was apparent in the wider interview data. For
example some nurses expressed their beliefs about SUD being a process that was complex
and many faceted with influences from mental health, social issues and larger societal
influences such as colonization and poverty, making it the result of extrinsic factors. Other
participants expressed beliefs about SUD being a matter of choice and thus the result of
intrinsic factors.
When exploring these dominant paradigms purposively in the analysis, it appeared
that participants who believed in extrinsic influences as a factor in SUD were less likely to
describe SUD as a choice and more likely to perceive it as a disease process. For example,
one participant saw SUD as “an illness just like anything else, so that they need to be treated,
we can’t say no we can’t do this because, I mean, it’s an illness too, it’s just harder to deal
with” (Participant One). Another participant reiterated this saying “I honestly just think of it
as their disease process” (Participant Six). Similarly, Participant Eight identified that the

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perceptions of SUD differ among ED nurses; however, she demonstrated her beliefs about
SUD by stating that PWSUD who are withdrawing in the ED are
a lot sicker than some people think, or most people think…because [the perception
is]it’s like a done to yourself kind of thing…If they’re managed properly, they’ll be
fine, but if you have someone coming off of opiates, who is a hardcore opiate user,
they’re sick. Like they almost need [an] Intensive Care Unit [ICU] and then keeping
them there because they want to use still and like it’s a constant struggle for them and
they know if they use they’ll feel better.
Another example of this perspective is evident in assertions made during the interviews about
larger social issues that can be part of SUDs. For instance, Participant Seven observed that
“often there’s many different things involved with people with addictions, as far as
psychological factors of why they are addicted. Is it depression? Is it abuse? What has done
that?” Several other participants commented on the way in which some PWSUD may also
be considered doubly-marginalized. For example, participants explained that PWSUDs may
experience stigma as a result of the SUD in addition to other social marginalizing factors; for
example, poverty, ethnicity, unemployment, and many of the other social determinants of
health. This participant explained: “they’ve got no homes, they go to shelters or they are
from other communities…and they have nowhere to go and they end up on the streets and so
they just live on the street almost all their lives” (Participant Nine). While these participants
recognized that not all people with SUD experience this double marginalization, one
participant commented:
I find the majority of people that we see with SUD tend to come from backgrounds
that are pretty…what’s the word I’m looking for?...they come from broken

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homes…they were raised on, they’re First Nations, they were raised on reserve where
they had limited resources, education levels are usually low, support systems are
lacking, they may have been raised by a single parent, they may not even have been
raised by their own parents themselves.…Access to health care may have been
limited and so it’s almost like that cycle continues. They… they’re exposed to that in
their childhood and then they grow and become an adult and they continue in that
lifestyle where they probably don’t have a very high level of education, access to
services may be limited, um their income may be limited, they may not even have a
job, they may be relying on the government for social assistance, welfare whatever it
may be. So… they’re lacking in a lot of important… I guess determinants of health.
(Participant Three).
Some of the participants demonstrated beliefs consistent with an understanding of the cause
of SUD as something extrinsic to the client. They placed emphasis on the influence of the
social determinants of health and trauma. For example, Participant Nine, a nurse with 12
years of experience in the ED and 22 years of experience in nursing, expressed empathy for
PWSUD and described this as a necessary part of caring for PWSUD. She made reference to
the difficult situations that patients find themselves in and her belief that SUD is not a choice
because people would choose differently. Importantly, this participant also spoke about
impact on nurses that seeing people in distress has.
They have vicarious trauma because of dealing with all this stuff. So being an Emerg
nurse, I think it’s a gift. You need to have passion to be a good Emerg nurse. You
need to have humor, cause if you don’t you go insane. Because of the things that you
see, and the things that you hear, and the things that you have to deal with, and I have

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a soft spot with people with addictions and with alcohol abuse, just because I always
think that if they have a choice, they wouldn’t be in that kind of situation. So I say
they have no choice, they probably really didn’t [ever] have any choice, that’s why
they’re in that kind of situation. (Participant Nine)
Through the analysis of the data, a smaller group of participants explained how they
perceived SUD as a matter of personal choice. One participant provided a very clear example
by saying “I look at it as a choice, it’s a choice of his life. He owns his addiction and I have
no problem with that” (Participant Two). While others made statements about personal
responsibility for SUD and differentiated SUD from other illnesses. For example, participant
12 stated that she thought nurses often differentiated between “people that have real illness
not like an illness that they, you know brought upon themselves, which is unfortunate”
(Participant 12).
Many of the participants commented on the perceived unwillingness of PWSUD to
seek and accept treatment. While some of the participants expressed hope, they also
identified that in their experience many PWSUD are “not open to like [change], they don’t
want to really accept much treatment” (Participant Five). This led some participants to
express frustration. For instance, when speaking about PWSUD who use alcohol, one
participant stated, “we have people that do [that] to themselves, constantly come in, get you
know, rehydrated, get sober [and] leave, [and] don’t seek any counselling (Participant 10). A
few of the participants made assumptions about PWSUD and the level of personal
accountability that is taken for self-care. For example, one participant described her belief
that “they [PWSUD] don’t care, they go off and they drink more and drink more”
(Participant Two). Some of the participants expressed frustration due to their desire to

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provide help but being unable to do so. Participant 10 a nurse from one of the smaller sites
with 27 years of experience in the ED stated that “it’s kind of frustrating to think you can
help them but they don’t want to be …if you don’t want to be treated, you’re not going to
want to seek treatment”.
The nurse participants expressed a variety of attitudes and beliefs about SUD and
PWSUD that help to inform their practice. They expressed empathy towards PWSUD as well
as frustration with the iterative nature of providing care to some PWSUD. The frustration
expressed by these participants was often related to not being able to help in the ways in
which they would like to help which were informed by their beliefs and values.
Patient and Provider Interface
Participants identified the interface between the patient and the provider as a
significant influence on the experience of caring for PWSUD. The participants described
how their approach impacted the interactions they had as well as how client presentation and
cooperation impacted the interactions
Interpersonal Interactions. Throughout the interviews, the participants commented
on their interactions with PWSUD. Building rapport with clients was cited by the participants
as crucial for providing for the needs of the client. Some of the common threads through the
discussions were focused on the importance of respect and honesty, and a non-judgmental
approach to building strong therapeutic relationships. Many participants also identified
approaches that did not lend themselves to building rapport. Furthermore, several of the
participants noted the interpersonal challenges that often exist in providing care for PWSUD.
Two of the participants described approaching PWSUD with respect. One participant
stated her belief that “you need to treat everybody respectfully and because of that people are

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more open with me in terms of why they’re there” (Participant Four). She goes on to say:
It’s because I treat them with respect that they would even answer a question when I
say you know why did you come to emergency today? That’s the question I get, that’s
what I ask them and they tell me well I don’t want to go to the walk-in clinic because
people are mean to me or people have laughed at me or they won’t treat me at the
walk in clinic. And I think it all has to do with treating people respectfully and not
judging them when they’re sitting in front of you.
The other participant described how a lack of respect can interrupt the therapeutic
relationship because “if they can see that you’re not respecting them or you’re judging their
choices or their decisions then that relationship is not going to be able to be appropriately and
positively established” (Participant Three).
Honesty arose during the interviews as a concept integral to the therapeutic
relationship. One participant commented on the role of honesty on the part of the care
provider stating that
being honest with [PWSUD] is the most helpful approach… often just having an
honest conversation with them and saying look, I am here to help you, we’re going to
get through this. We’re going to do it together. ..I am not okay with you swearing at
me or calling me names or…being mean to me” (Participant Six).
This participant did note that her approach was carefully considered with any patient, whose
level of consciousness is compromised, not just those with PWSUD. When describing her
approach, another nurse denoted belief about honesty being reciprocal she explained “I think
just honesty is helpful. If you’re honest with them and then for most patients, they feel that
they can be honest with you if you just remain non-judgmental” (Participant Eight). Further

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to this, a third participant commented on the importance of honesty in developing a
therapeutic relationship that benefits the nurse’s ability to complete a thorough and
comprehensive assessment. The more a nurse learns about a client, the better able he or she is
to plan appropriate care resulting in improved client outcomes. This participant’s approach
was to
just try to come at them [PWSUD] in an approach of being really real and honest,
non-judgmental and just trying to get them to trust me so we can get to the bottom of
what’s all the substances they’re using, so you can build that bond so that they can
access help if they need it (Participant Seven).
Judgment has been included in several of the excerpts in the sections on both honesty and
respect. It is clear that many participants believe a nonjudgmental approach to caring for
PWSUD is important. Participant Eight commented on the importance of being
nonjudgmental. She shared a story of caring for a client that required her to adopt a nonjudgmental approach in order to insure the client could access the care she needed. The
following is an excerpt from that story.
I had a girl come in who, she was, I forget what she was detoxing off of, but
throughout assessing her, getting to know her a bit more…she was a young girl, she
was only 19, but then throughout the assessment I got that she had been here…
prostituting and she had quite a few sores in her mouth and the issue she came in for
her eye was probably STI [sexually transmitted infection] related kind of thing. So
in that moment I tried to really withhold my expressions and stuff to be like ya, that’s
okay, a prostitute, that’s fine, we’ll get you checked out, maybe we’ll get you some
HIV testing, like what drugs have you been [doing]? I try to just be more like

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unaffected by their story because I find if you’re like “you’re prostituting!”, they’re
like oh God, why did I say that? And then it becomes a big deal, whereas if you’re
kind of just chill about everything, then they’ll open up to you a lot more and she
ended up staying. This was her initial contact with emergency rooms and…initial
contact of being positive and not judgmental.
This narrative exemplifies how important and how difficult remaining nonjudgmental can be
for nurses.
Several of the participants discussed approaches that they had tried or had witnessed
that they felt were less likely to allow for the creation of a therapeutic relationship between a
nurse and a PWSUD. The participants who commented on approaches that were less
successful spoke about expectations, and attitude. The consensus seemed to be that
expectations of people actively using substances, needed to be adjusted to reflect the
individual’s current abilities. One participant simply stated “getting mad at them isn’t
helpful, and having unrealistic expectations of what they can accomplish when they’re
intoxicated” (Participant Six) while Participant Seven said “never try to argue with a
somebody on substances…it doesn’t work, so don’t even try”. The potential outcome of the
wrong approach with someone whose cognitive abilities are impaired, was identified by the
participants as potentially volatile behaviour on the part of the client. One participant
described her observation that at times, nurses new to the ED can be overly “aggressive with
[PWSUD]…Being aggressive and not treating them with respect just tends to escalate people
who are not fully in control of their mentation” (Participant Four).
Challenges in interacting with PWSUD were identified by the majority of the
participants and several noted that being skilled at communicating with an agitated patient is

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important in the management of someone who is actively using substances. Participant One
described, “if the [PWSUD] presents cooperative and calm then it’s much easier, of course,
to handle… If the situation is out of control and everybody is adding to that agitation, it
makes it that much worse”. Since nursing is interactive, it is crucial that the nurse not
contribute to the escalation of a patient’s behaviour but rather work to defuse potentially
dangerous situations.
Many of the participants talked about safety in the context of caring for PWSUD.
They perceived that PWSUD who were actively using substances, were an increase risk to
the personal safety of the ED staff as well as the personal safety of other individuals in the
ED. The concept of safety arose in ten of the interviews.
Two of the participants specifically identified their perceived risk to the general
public. They described their desire to insure that people were protected from PWSUD at risk
for violence. Participant Six talked about her beliefs about her responsibilities.
As an Emergency nurse, I do have to be aware of the safety of my colleagues and
myself and the public that’re in the Emergency department because I acknowledge
that anybody with altered level of consciousness…is at risk for some verbal violence
but also physical violence, predictable or unpredictable”.
Another nurse affirmed this saying she tries to insure “the regular community …feel safe in
our ED” (Participant Two). These participants did not offer specific practices that they use to
insure the safety of everyone.
The safety of the nurses caring for PWSUD arose as a significant piece of the
experience of caring for PWSUD. Aware of the safety concerns associated with caring for
PWSUD, many participants developed strategies and plans to maintain their personal safety

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and their colleagues’ safety when caring for those with PWSUD. There were several
examples of this within the data. Examples included varying their approaches to PWSUD
from those they might use with other clients, involving outside agencies such as the RCMP
and insuring that they have escape plans or safe places they can go if the situation becomes
unsafe. One participant from one of the smaller sites, where there are a maximum of three
staff on any time, explained “before [I] can help them [the PWSUD], I need to make myself
safe…I can lock myself in our med room, it has a lock” (Participant 11). The need to be safe
was echoed by another nurse from a rural site who described how she tries to maintain her
safety, “the only thing is safety, if they’re going to hit you don’t confront them…step away,
make sure you’re safe” (Participant 10). The nurses from the smaller sites were more likely
to discuss strategies that they could enact alone while nurses from the urban site clearly
recognized they had resources to help. One nurse from the urban site stated that when
confronted with a potentially violent client, they can call the code white team or security to
help (Participant Four and Participant Six). Five of the participants stated they had received
training focused on the agitated or aggressive client such as “code white” (Participant Nine).
Nurses from both the rural and urban site are included in that number.
Five of the participants talked about PWSUD and the Royal Canadian Mounted
Police (RCMP). Three participants described how they felt they could rely on the police to
assist with aggressive clients with SUD. Participant 10 described “sometimes they [PWSUD]
can become abusive…and we just think…let’s call the RCMP and let them go to cells”.
Participant 6 also explained “of course we use the RCMP when we need to …cause there’s
no doubt there’s safety issues that come across with this group…[sometimes] it is the right
place for them [PWSUD] to go to the RCMP cells for a little bit so that we know they’ll be

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safe”.
This theme described the participants’ beliefs about and attitudes toward PWSUD and
SUD. While the participants demonstrated a variety of beliefs and attitudes ranging from
intolerance of the behaviour to acceptance and understanding of the deeper issues associated
with the behaviour, many participants also noted that approaching a PWSUD with genuine
care, respect and the desire to engage in a therapeutic relationship was important to
developing rapport. However, many participants also noted that some PWSUD can constitute
a risk to the safety of themselves, the medical staff that work with them and the general
public and are aware that they need to keep themselves safe.
Summary
This chapter described the participants’ experiences of caring for PWSUD in the ED
setting. The analysis of the interview data resulted in the emergence of three themes
including: PWSUD in the ED which outlined the participants’ beliefs about the role of the
ED and the ED nurse with respect to caring for PWSUD; Organizational Barriers where
participants perceived barriers to caring for PWSUD were described; and Beliefs and
Attitudes where the nurses’ beliefs and attitudes about SUD and PWSUD were described.
The following chapter will discuss the findings of this study in relation to practice, policy and
future research.

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Chapter Five: Discussion
This qualitative description study examined how 13 RNs working in the ED
experienced caring for PWSUD. The research has provided insights into the challenges that
RNs face caring for PWSUD in the ED setting, the need for resources specifically aimed at
improving outcomes for PWSUD, the varying attitudes and beliefs that RNs hold regarding
SUD, and PWSUD and how these impact care provision. The following chapter provides a
discussion of the key findings as they related to existing literature, as well as assessing the
strengths and weaknesses of the research and key contributions to nursing policy, practice,
and education.
Nurses’ Experiences of Caring for PWSUD in the ED
Through analysis of the verbatim transcripts, three major themes were identified as
influencing RNs experiences of caring for PWSUD: the role of the ED and the ED RN in the
care of PWSUD; organizational factors such as access to education and training and the
availability of resources both in the ED and outside the ED; and, personal beliefs and
attitudes about SUD. Overall, the nurses identified caring for PWSUD in the ED as a
challenging endeavor for which they felt underprepared and under supported. They held a
variety of beliefs and attitudes about SUD, as well as what the role of the ED nurse should be
in the care of this population. The beliefs about SUD ranged from SUD as a disease process,
to SUD as a choice and more closely related to a personal failing. Some nurses were very
open to caring for PWSUD in the ED while others believed that PWSUD could be better
cared for in other settings. Most RNs demonstrated some frustration in caring for PWSUD,
largely related to a lack of resources, challenges in interpersonal interactions, and personal
beliefs about SUD. Finally, while few nurses in the interviews identified themselves as

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having stigmatizing attitudes toward PWSUD, stigmatization was prevalent in the language
used, the examples provided, and the nurses’ perceptions of how PWSUD were treated in the
ED.
Despite all the perceived challenges and barriers to providing good care to PWSUD
in the ED, all of the nurses interviewed in this study described an ongoing desire to improve
care for this population. Frustration was evident both explicitly and implicitly in the
interview transcripts and was often attributed to feeling unable to support PWSUD
adequately. Participants identified difficulty in accessing appropriate and timely resources for
PWSUD as well as in providing evidence-informed care, resulting in clients who return to
the ED frequently with similar issues. The following sections will explore these key findings
as they relate to the existing knowledge and literature around SUDs.
PWSUD in the ED
During the interviews, RNs described how they experienced caring for PWSUD in
the ED. They identified that the primary purpose of the ED was to provide crisis intervention,
maintenance of patient safety, and physiological health management, perceiving that this did
not always match the needs of patients presenting with SUD or SUD-related issues. Whether
the participants believed that the ED was the correct place for PWSUD with non-emergent
issues to seek treatment or not, they all identified their desire to provide good care and their
frustration when PWSUD did not receive the level of care or help they should. This theme
raises questions of role legitimacy and compassion satisfaction for nurses working in the ED
setting.
Role legitimacy was defined by Skinner, Roche, Toby, & Addy (2005) as concerning
the “perceived boundaries of professional responsibility and right to intervene” (p.450). The

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participants felt split on whether the non-emergent care needs of PWSUD really were the
concern of the ED and the associated staff. Some felt that non-emergent or non-urgent care
needs were not appropriate to the ED, while others felt that ED nurses should treat whoever
comes through the door and recognized the limitations that some PWSUD may face when
attempting to access health care.
In the northern regions of Canada, particularly in the rural north of BC, access to
specialized care can be difficult, even for those who are not already potentially marginalized.
Distance and climate can make regular travel difficult and expensive, and can mean that
some individuals face limited options when attempting to access care (De Leeuw et al., 2002;
Parker et al., 2012). As such, many people may choose to access the ED in the absence of
access to other healthcare services (Kennedy et al., 2014; Uscher-Pines et al., 2013). As
previously highlighted, PWSUDs may lack ready access to regular healthcare services, such
as primary care providers, by virtue of their health condition or related behaviours (Cooke,
2017). Thus, it becomes very important that the health care settings that are available are able
and willing to assist PWSUD with care.
The participants in this study identified that many PWSUDs lacked access to other
healthcare services and that this was even more challenging for those located in rural and
remote settings. The ED nurses recognized that they must be able to provide diverse services
to a wide range of patients, including PWSUD and have organizational support for this. This
need for legitimization was also evident in the work of both Skinner et al. (2005) and Ford, et
al (2008; 2009), who identified that support in the workplace is the most important factor in
legitimizing work with PWSUD. Ford et al. (2009) found that workplace education and
training, in conjunction with workplace support for interventions related to caring for

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PWSUD, was the most effective way to improve therapeutic attitudes towards PWSUD and
that education alone was insufficient to enable significant change. Likewise, Skinner et al.
(2005) also found that organizational or systems-level interventions were necessary to
improve role legitimacy and to create a healthcare culture that supports the management and
support of those PWSUD.
The need for role legitimacy and support is not limited to the nursing profession and
has emerged as an important issue for many other health care providers. Role support is
defined as the “belief that colleagues and supervisors provide support in their work”
(Loughran, Hohman, & Finnegan, 2010, p.243). For example, an American study by
Loughran, Hohman, and Finnegan (2010) investigated role legitimacy by undertaking a
survey of social workers (n=147) and social work students (n=45) that care for PWSUD.
Data were analyzed using multiple regression models and they identified that experience
caring for PWSUD, education specific to the work of caring for PWSUD, and support in the
role were important to the development of role legitimacy. Their findings corroborated those
of Ford et al., (2008), who also found that increased education combined with greater role
support has the greatest impact on the development of role legitimacy and therapeutic
attitudes. Moving forward, an increasing focus on organizational and professional supports,
including targeted education on SUDs, may provide a viable means of promoting more
effective and patient-centred care for PWSUDs.
Wanting to Do the Right Thing
Participants in this study described at length the frustrations they felt when providing
care to PWSUD in the ED setting. A topic that surfaced time and again was that PWSUD
often received a level of care that did not meet their complex needs. The RNs in this study

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perceived that these gaps in care arose due to institutional limitations, such as a paucity of
resources and a lack of adequate time and space to provide complex psychosocial care. This
left many of the participants feeling a lack of satisfaction with the job they perform and led to
many feeling disengaged. Burtson and Stichler (2010) refer to such disconnections between
practice ideals and realities as resulting in a lack of ‘compassion satisfaction’, further
contending that low compassion satisfaction can result in the nurse “withdrawing
emotionally from patients for self-protection” (Burtson & Stichler, 2010, p. 1820). Therefore,
increasing compassion satisfaction could be an integral part of improving the experience of
caring for PWSUD for both nurses and clients.
One way to improve compassion satisfaction and promote nurse engagement with
PWSUD is to create care pathways to assist RNs in clinical decision-making around
substance use and PWSUD (Demirkol et al., 2017). Clear guidelines will provide nurses with
confidence that they are in fact providing optimal care to this group of clients. Care pathways
are “designed as recommendations for optimal management plans” that focus on increasing
the quality and efficiency of care provided by health care facilities (McCue, Beck, &
Smothers, 2009, p.43). Clear guidelines and expectations for the care of PWSUD could have
the effects of improving the confidence and competence of ED nurses caring for PWSUDs,
reducing variations in care and optimizing the application of evidence-based practices
(McCue et al., 2009). Additionally, care pathways assist in directing patient populations to
access the most appropriate care, in the most appropriate place, at the most appropriate time
(Adeyemi, Demir, & Chaussalet, 2016).
Another potential benefit of adding care pathways is that standardizing care and
benchmarking care will highlight the need for greater compassion and effective care, while

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potentially eliminating some of the stigma and effects of personal attitudes and beliefs from
nursing care. This may lead to improvements in the experience of care and potential
outcomes for clients. Given that the participants in my study identified a desire to help
PWSUD when they present to the ED, having improved outcomes and clear pathways may in
turn reduce the frustrations experienced by many nurses working in EDs. While it may be
unrealistic to change each individual nurses’ beliefs and attitudes toward PWSUD, as these
have developed over a lifetime of experiences and may not be easily altered, it may be
possible to alter therapeutic attitudes toward caring for PWSUD through care pathways and
organizational supports (Ford et al., 2009).
Organizational Barriers to Care
The second theme that emerged from the data analysis, organizational barriers to care,
captured examples of where organizational or institutional structures negatively impacted the
nurses’ perceived ability to provide good or excellent care to PWSUD. First, participants in
this study described a low level of preparedness to care for PWSUD, with many reporting
inadequate educational preparation and training. Second, participants identified a lack of
available resources and supports to assist them in providing care to PWSUD. Finally,
participants recognized the population distribution of the northern BC region, in concert with
less frequently available or accessible training opportunities and resources, as being
challenging (Puskar et al., 2016). These will now be discussed further.
Preparedness
The concept of preparedness encompassed the participants’ perceptions of their own
readiness or their perceived ability to provide good care to PWSUD. Overwhelmingly, the
participants identified that they felt they had insufficient training and education to prepare

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them to care for this complex population of patients. Such feelings of being insufficiently
prepared or knowledgeable about the needs of PWSUD are consistent with existing studies
exploring PWSUD (Ford et al., 2009; Kelleher & Cotter, 2007; Happell et al., 2002; Lovi &
Barr, 2009; Monks et al., 2012; Morgan, 2006; Raistrick et al., 2008). For example, in their
quantitative study, Happell et al. (2002) conducted a survey of 308 nurses, of which 134 were
RNs. Happell, et al. used a modified Substance Abuse Attitudes Survey, the results of which
indicated that while nurses regularly screened for SUD, they required more training in the
identification and treatment of SUDs. This study identified that increased training was
needed not only for specialist nurses, but for all nurses across the continuum of care. My
study concurred, with participants identifying the desire for more education on SUD.
Similarly, in their qualitative study, Monks et al. (2012) conducted a study of nurses caring
for PWSUD in an urban setting. They identified that nurses lacked confidence in managing
PWSUD’s health care needs and that increased knowledge and education would be necessary
to improve the provision of care and the nurses’ experiences of providing care to PWSUD.
Participants in my research identified that their preregistration education did not adequately
address the needs of caring for PWSUD. This supported the findings of Lovi and Barr
(2009), who identified that SUD are inadequately addressed by general RN education in
Australia and that more specific education during nurses’ training could be beneficial to
improving health outcomes and satisfaction with health care for PWSUD.
Overall, by undertaking this qualitative study, my research offers a more in-depth
description of nurses’ day-to-day experiences of caring for PWSUD, that served to highlight
this need for further education and training both pre and post registration. Additionally, the
rural and northern focus of my study offers a unique view of this issue, thus contributing to

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the existing knowledge in the field. However, work place training and education in the rural
context can be difficult to provide and maintain, largely related to the cost of travel, human
resource limitations, and high turnover of health care workers (Ellis & Phillip, 2010; Puskar
et al., 2016). Several of the participants in my study described the difficulty they had in
accessing education due to its lack of availability within their workplace and the challenges
of travelling long distances for educational opportunities. For example, one participant that
worked in a smaller site stated “education here, in this area is kind of very less than in [the
larger site]” (Participant 13). Thus, innovative and imaginative solutions must be sought to
ensure nurses in rural and remote settings feel they have adequate support to care for
PWSUD.
There have been few studies that examined workplace education for nurses in rural
and remote settings. For example, Ellis and Phillip (2010) conducted a course evaluation of a
Mental Health Emergencies Course that sought to develop clinicians’ skills in mental health
emergencies. The course was attended by rural and remote ED nurses in Australia. Ellis and
Phillip used pre (n=475) and post (n=163) workshop questionnaires, as well as telephone
interviews with 44 self-identified respondents. The pre and post workshop questionnaires
were not linked and it was impossible to estimate improvement in this way. However during
the interviews, Ellis and Phillip (2010) found that participation in the workshop improved
nurses’ attitudes towards those with mental health issues, feelings of role legitimacy, and
preparedness to manage mental health emergencies. This was most evident in the
participants’ reports of improved communication with people with mental health
emergencies. Since mental health and substance use are often closely linked, it may be that
similar workshops aimed more specifically at SUD and PWSUD would have similar effects.

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Further research could examine how educational supports impact the perceptions of PWSUD
and the delivery of nursing care.
Resources and Supports
During the interviews, participants in my study described numerous barriers that
impacted upon their ability to provide high quality care and expressed frustration in relation
to these perceived barriers. Frequently, the blame for their frustration was placed firmly on
the organizational structure and availability of resources for PWSUD. Lack of resources and
supports were indicated as being associated with repeat visits to the ED for SUD-associated
complaints. Having people return again and again with similar or identical complaints left the
nurses feeling like they were not able to make a difference.
These findings were consistent with existing studies in the following ways. First,
there are gaps in the provision of services for MH&A, particularly in the treatment of SUD.
These gaps exist in rural and remote settings and occur as a result of disparity in access to
appropriate treatments between those living rurally and those residing in urban centres
(Broffman et al., 2017). My study was conducted in the context of northern BC, where many
communities are considered rural by virtue of their distance to a larger metropolitan area.
Similar rural impacts were uncovered by Davis et al., (2016) who investigated
disparities in access to care in rural South Dakota. They used a cross sectional address-based
survey to assess whether people in rural settings perceived themselves as being able to access
or obtain care for alcohol and substance use issues. They found that individuals living rurally,
and Indigenous people living on reservations, were less likely to obtain all the care they
needed. Likewise, Broffman et al. (2017), in their study of rural South Dakota, described a
number of barriers, including stigma associated with SUD experienced by PWSUD, that

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influence the detection of SUD by health care providers. They also identified a high ’needfor-care threshold’ for seeking care by those experiencing SUD as a barrier to care (2017, p.
72). Potential solutions to the barriers to access to care may include the increased use of
technology, such as telehealth or health care appointments facilitated with video technology.
Further research into the use of peer support networks and increased community involvement
as a way to support PWSUD in their home communities could also facilitate improved health
outcomes and experiences for PWSUD.
In the context of SUD, organizational structure can reinforce stigmatizing attitudes
that make it difficult or unappealing for PWSUD to seek assistance. This was identified by
several participants in my study. One in particular stated that PWSUD sometimes do not seek
care because they feel disrespected or judged by health care providers but also by other
patients that are seeking care in other health care settings (Participant Four). These findings
are congruent with those of Chang et al. (2016), who emphasized how institutional dynamics
can reinforce the stigmatizing process and further increase the barriers to care for PWSUD.
Health care workers who do not have the skills and abilities to manage the complex
needs of PWSUD, a paucity of community resources for ongoing monitoring and care for
those with PWSUD, and low role legitimacy for the care of this population can negatively
impact the experiences of PWSUD in the health care system. However, institutional policy
and practice can also have very positive influences on the destigmatizing process, thus
increasing access and quality of care to PWSUD. An example of this is described by Ford,
Bammer and Becker (2008), who found that the most effective interventions to improve
nurses’ therapeutic attitudes were to increase role support along with workplace education.
Ford et al. (2008) used data from a cross sectional survey of nurses in the Australian Capital

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Territory. The survey included personal characteristics, attitudes towards substance use, and
professional practice factors. Multivariable linear regression of the data was undertaken.
They found that workplace education and role support resulted in improved knowledge,
comfort, and confidence in ability to care for PWSUD, as well as increased legitimacy of the
work for those carrying it out. In settings where it is not realistic to have specialized services
in every community, such as northern BC where the population is dispersed across a large
geographical area, generalist nurses and primary care providers (physicians and nurse
practitioners) must have a good working knowledge of caring for PWSUD as they may be
the only resources available in some communities.
One institutional approach that has been demonstrated to have positive outcomes is a
harm reduction approach (Ball, 2007; British Columbia Harm Reduction Strategies and
Services, 2008; Hilton, Thompson, Moore-Dempsey, & Janzen, 2001; Lightfoot et al., 2009).
Harm reduction “is characterized by easy access to help and care, help on the user’s terms
with few conditions, a focus on how to reduce injury related to health, hygiene, sexual
conduct, family and economy, and a focus on an anti-stigmatizing attitude” (Edland-Gryt &
Skatvedt, 2012). While harm reduction, as an approach to care, by no means rules out
treatment and abstinence as a possible strategy to manage SUD, it does not make it a
requirement. Harm reduction may provide ED nurses with a set of tools and interventions
that they can implement for every client with SUD. For example, providing education on
good practice for injecting, providing clean supplies, or offering testing for blood and body
fluid borne diseases are just some of the services nurses’ could champion. This may enhance
their compassion satisfaction as they are meeting the needs as described by the client and are
helping. Further exploration of ways to develop positive institutional cultures represents an

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important opportunity for future research that may lead to improvements in patient and health
system outcomes.
Beliefs and Attitudes
The participants in my study discussed or demonstrated a variety of beliefs and
attitudes regarding SUD and PWSUD during the interviews. The beliefs demonstrated by the
participants about the nature of substance use varied from those who believed SUD to be a
disease process, to those who believed substance use was a choice. Some participants
recognized the larger social contributions to the issue of substance use, while others viewed
substance use as a personal concern rather than a societal issue. These findings were
consistent with those described by many of the authors presented in the literature review
(Adams, 2008; Chappell & Schnoll, 1977; Chu & Galang, 2013; Fischer et al., 1975; Happell
et al., 2002; Harling & Turner, 2012; Howard & Holmshaw, 2010; Kelleher, 2007; Kelleher
& Cotter, 2008; Lindberg et al., 2006; Lovi & Barr, 2009; McLaughlin et al., 2003; Morgan,
2006; Morley et al., 2015; Pinikahana et al., 2002; van Boekel et al., 2014; Van der Woerd et
al., 2010). For example, van Boekel, et al. (2013) carried out a literature review of 28 articles
aimed at discovering the attitudes of health care professionals across western countries. They
found that health care professionals commonly held negative views toward PWSUD when
compared to attitudes towards people with other disorders such as diabetes or heart disease.
However, they found that those with increased contact with PWSUD were more likely to
hold neutral views of SUD and PWSUD. Their review consisted almost entirely of
quantitative studies (n=26). My study offers a complementary perspective of this issue as it
was qualitative in nature and participants had more opportunity to offer their own perspective
on their beliefs and attitudes. An example of this is that while many participants discussed

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the challenges they faced in providing care to PWSUD, they also offered their desire to
provide high quality care to the clients.
The development of beliefs and values related to any topic is a complex process that
is influenced by the individual’s personal values, life histories, and experiences in both
personal and professional spheres, as well as wider societal values (Harling & Turner, 2012).
As a result, nurses’ attitudes and beliefs in areas related to SUD have been found to closely
mirror those of the general population. Thus, it is reasonable to assume that the beliefs and
attitudes of RNs in this study may also have similarities those of the general population
(Ford, 2010). This is significant because it indicates that in order to change beliefs, a change
in society’s perception of SUD and PWSUD will need to occur. This presents another avenue
for further research.
An interesting addition from my study is that regardless of the attitudes and beliefs
held by the individual participant, all expressed a desire to help PWSUD and frustration at
not being able to help. That being said, their perspective on what help entailed differed. Some
participants perceived help as meeting the expressed needs of the client, while others
perceived help as assistance in cessation of substance use. From my perspective, I believe
this is an important finding as it indicates a discrepancy in the definition of the concept of
help and how it relates to providing care to PWSUD. While helping within nursing care is
not a new phenomenon, there is little literature available concerning what this concept means
in the context of nursing. The lack of a clear understanding of how helping is defined is
significant, as it indicates that the nurses in study sites were not clear on their role in the care
of PWSUD. I believe that a clearer understanding of what help means in the context of

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nursing could lead to better, more patient centered practices that result in positive outcomes
for PWSUD.
Patient Provider Interface
The third subtheme to emerge in this category described the interface between the
patient and the care provider, and the impact this had on both role legitimacy and compassion
satisfaction. PWSUD and health care providers have often had a relationship that consists of
a kind of mutual distrust (Chang et al., 2016; Monks et al., 2012). The participants in this
study described this same relationship. Patients were described by the participants as being
difficult to manage, sometimes violent and manipulative, and at times unwilling to help
themselves. Monks et al. (2012) described a cycle where PWSUD exert negative behaviours
as a method of having their needs met, the PWSUD are then labelled by nursing staff as
difficult, and are then labelled as difficult on subsequent visits further impacting the care that
is provided. This treatment cycle reinforces PWSUD’s feeling that their needs will not be
met, resulting in further negative behaviours, and so on. In order to end this negative cycle,
one of the participants in the interaction needs to alter their input and I would argue that this
falls into the professionals’ purview. Nurses must alter their end of the interaction in order to
alter the outcome. The ability to change this cycle will require education to stigmatizing
views, as well as operational and organizational support (Ford, 2010; Ford, 2011;
McLaughlin et al., 2006; Monks et al., 2012).
Stigma. Stigma is defined as “not simply a discrediting individual characteristic, but
rather as a social process involving labelling, stereotyping, status loss and discrimination that
unfolds when unequal power dynamics exist” (Chang et al., 2016, p.91). Stigma was visible
throughout the data collection, particularly in relation to the language used to describe

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PWSUD and their actions. Participants each provided a description of a time they cared for a
PWSUD. Within these reflections, there were many examples of stigmatizing language. For
example several participants expressed the need to be wary of clients who were actively
intoxicated because “sometimes they can become abusive, verbally and physically”
(Participant 10), while another stated: “substances have upped their [PWSUD] violence
scale” (Participant 11). Only one of the participants qualified her awareness of the potential
for violence by stating her understanding that “anybody with an altered level of
consciousness is at risk for some verbal violence, but also physical violence, predictable or
unpredictable” (Participant Six).
Several participants explicitly identified stigma as a systemic issue, one that was
pervasive not only within the ED but also in the rest of the hospital setting. One of the
participants provided an example of this and described a situation in which a PWSUD, who
was well known to the ED staff, presented with symptoms that were not usual for the person.
The ED nurses believed that something more sinister and not directly related to SUD was
occurring and the person was admitted to hospital. Attempts to transfer the patient from the
ED to the most appropriate clinical unit were made, but the participant recalled that they
experienced a great deal of difficulty convincing the accepting unit that a higher level of care
was necessary as assumptions were made about the person based on their history of SUD.
This resulted in a 12-hour delay in transfer from the ED to the unit. The client was very ill
with an issue unrelated to SUD and the client required a high level of ongoing medical
intervention to survive (Participant Seven).
Other participants characterized PWSUD as not wanting help. These participants
perceived PWSUD to be often unwilling to accept help or seek lifestyle changes. Many of the

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participants who described PWSUD as not wanting help, demonstrated frustration due to the
client’s lack of participation or desire to receive care. For example, Participant Five
explained “because as a nurse, I’m coming from that compassionate kind of perspective of ‘I
want to help you’ and then there’s also that, like, ‘if you keep putting yourselves in these
situations, it’s really hard to help you’. Within these examples, stigma is evident in the
othering that the participants engaged in.
Since beliefs about PWSUD vary across society and include stigmatizing beliefs, it is
not surprising that at times institutional values also contribute to reinforcing these negative
stereotypes (Harling & Turner, 2012). Recognizing that stigma is a societal issue, rather than
an individual issue, is necessary to address stigma at all levels: societal, institutional and
personal (Chang et al., 2016). This can be done in a number of ways including raising
awareness among the general population about PWSUD, legitimizing SUD as an illness, and
placing value on the care of PWSUD both by appropriately funding resources and by
implementing policy and practice guidelines (Livingston, Milne, Fang, & Amari, 2011). As
stigma toward PWSUD relates to nursing, increasing education about caring for PWSUD in
both pre-registration education and workplace education may increase understanding of
PWSUD and in turn, may contribute to improvements in health care delivery (Miles,
Chapman, & Francis, 2015). This must be done not only in settings specific to MH&A, but
also in acute care and community-based settings. This will provide nurses with knowledge
and skills for meeting the needs of PWSUD across the continuum of health care services. For
example in acute care settings this may include the provision of education to foster effective
pain management, an aspect of care that is highly challenging for PWSUD. Increasing
nurses’ understanding of how PWSUD experience pain and pain control could enable nurses

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to better advocate for patients’ needs and thus have better success with meeting the needs of
their patients (Morely et al., 2015).
Overall, my study has examined the complexities of caring for PWSUD in the ED
context and has addressed some of the existing gaps in the literature with respect to
understanding nurses’ experiences in caring for this population. In concert, this research has
corroborated the findings of other studies exploring SUD and has provided valuable insights
of RNs caring for PWSUD in the rural and small urban settings in northern British Columbia.
For example, my study was congruent with the findings of other studies that identified that
nurses hold some negative beliefs about SUD and PWSUD (Adams, 2008; Baldacchino et
al., 2010; Chu & Galang, 2013; Happell et al., 2002; Johnson et al., 2005; Kelleher, 2007;
Kelleher & Cotter, 2009; Pinikahana et al., 2002; Raistrick et al., 2008; Spence et al., 2008;
van Boekel et al., 2014). However, this study demonstrated that despite some negative
attitudes and experiences, nurses still wanted to provide high quality care to improve the
health and wellbeing of PWSUD. Furthermore, I found that nurses are cognizant of the
impact of organizational and institutional resources on their experiences of providing care,
and the need for improved education and support.
Recommendations for Education, Policy and Practice, and Research
This research has brought to light numerous areas that warrant further investigation as
a means for improving health outcomes for clients and nurses’ experiences of caring for
PWSUD. These recommendations for education, policy and practice, and research will now
be presented.

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Education
All of the participants in this study identified that education and training specific to
SUD was limited both prior to professional registration and during their work as an RN.
Increasing preregistration education related to SUD is warranted, both within the MH&A
content but also within other areas of nursing, such as medical-surgical nursing, perinatal
nursing and geriatric nursing. Further educational opportunities may contribute to greater
confidence and competence when caring for the population and may also highlight that
PWSUD exist in every sector of health care and will be experienced by most nurses.
Increased exposure to PWSUD, along with adequate knowledge about SUD, could also serve
to decrease the stigma associated with this issue and work to normalize the provision of care
for this often marginalized group. Furthermore, workplace-specific educational opportunities
geared at improving nurses’ skills within their particular area of practice will further
contribute to increased skill and confidence in caring for this population of patients.
Educational pathways that are integrated into nurses’ ongoing training may likewise
encourage those who regularly come into contact with PWSUD to remain up-to-date in their
practices and offer direction for the most current treatment and resources. This will place
increased organizational value on the care of PWSUD and serve to legitimize the provision
of care in the ED setting.
Policy and Practice
PWSUD are a highly stigmatized group who often suffer the stigma not only of SUD,
but also commonly because of other factors such as mental illness, poverty, homelessness
and sometimes racial stigma. It is important to acknowledge the existence of this injustice so
that we, as health care providers, who are tasked with providing unbiased care, can begin to

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create safe and appropriate health care spaces where assistance can be accessed by
marginalized groups. Policy and practice guidelines that support this endeavor are
imperative.
Since PWSUD do present to the ED with both urgent and non-urgent issues, it is
important that nurses have not only the education and training to manage PWSUD’s care, but
also the organizational support to do so. On a departmental basis, this support could be
provided by having local nurse champions who are there to support the decision making and
practices of other nurses. This could include role modeling best practices or supporting the
development and uptake of best practice guidelines to improve patient care. In addition,
ongoing monitoring of outcomes through evaluation would provide useful feedback that
could further inform the development of more responsive practices. Outcomes that could be
measured include whether nurses and patients report feeling more supported, as well as more
objective patient outcomes, including readmission to the ED for the same issue and long term
health outcomes. This would serve two purposes, 1) to ensure that the support exists for the
nurses, and 2) to legitimize the care of PWSUD in the ED. While nationally there have been
some initiatives to improve screening for SUD, more needs to be done to provide appropriate
and safe care to this group.
On a wider scale, value needs to be placed on the care of PWSUD and this could be
demonstrated throughout the health care setting by improving and expanding the available
services that are geared specially toward PWSUD. Several of the participants working in the
smaller centres suggested the creation of an ED (or section of the ED) specifically geared
towards addressing MH&A issues, where people accessing the ED would have access to

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quality patient-centered care that would address the holistic needs of the individual, including
any physiological and mental health concerns.
Further efforts are needed to explore more effective and responsive models of care for
PWSUD. Currently, many of the community resources that are available across this region
are based on an abstinence model. While this has an important role in healthcare for those
with SUD, harm reduction may also provide an alternative approach that could be beneficial.
In more rural and remote settings where physical services are most limited or not feasible due
to cost restraints or low population density, other forms of access to healthcare could be
considered including telehealth, peer support networks, and increased community
involvement.
Research
This research explored RNs’ experiences of caring for PWSUD in an ED setting.
While important insights were gained from this work, many more questions surfaced as a
result. Future research directions informed by this study could include investigating the care
of PWSUD in other tertiary health care settings, such as medical units or surgical units. This
could include both nurses and patients as participants in order to broaden the understanding
of the experiences. A comparison between rural and urban experiences of caring for PWSUD
in EDs could be conducted inviting not only RNs, but also physicians and other members of
the health care team to participate. This would provide a much needed interdisciplinary
perspective of caring for PWSUD in the ED setting. A concept analysis of help in the context
of nursing care might highlight how nurses define this concept, allowing for this term to be
better understood going forward. Since the participants in my study identified a disconnect
between their desire to provide good care and their ability to achieve this due to a lack of

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knowledge and organizational support, further investigation of the cognitive dissonance that
nurses experience when caring for PWSUD could elicit useful information. Finally, with
stigma still prevalent in the experiences of nurses working with PWSUD, research aimed at
decreasing or eliminating the stigma associated with SUD would be beneficial in improving
experiences for health care professionals and PWSUD alike.
Strengths and Limitations
To understand the experiences of nurses caring for PWSUD in the ED, a qualitative
descriptive study was undertaken with 13 RNs from northern British Columbia. As
previously discussed, the qualitative approach was congruent with the focus of the research
and was appropriate to addressing the research questions. Overall, the study generated a large
volume of rich data allowing for detailed and rigourous analysis. In addition, ongoing
reflexivity, in combination with sustained engagement with the data, supported the rigour of
the study. For example, a reflexive diary was kept throughout the duration of the research
that allowed me to situate my own beliefs and assumptions as they related to the data and to
track the data analysis. During the research, I examined my own bias and confronted my own
experiences of caring for PWSUD in the ED and made conscious effort to make my
interview schedule as value free as possible. Throughout data collection, I revisited my
reflexive journal and added to it. Analysis of the data also required me to examine my own
biases and beliefs, to be certain that I was reliably focusing on the voices of the participants.
One way that this was attended to was the use of participant stories and descriptions of their
experiences. This speaks to authenticity and to credibility of the research process (Lincoln &
Guba, 1985). Additionally, ongoing support from the supervisory team provided an important
opportunity for quality checks and guided both the analysis and the data collection. Overall,

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the study findings have provided a rich description of RNs’ experiences that has addressed
gaps in the literature by exploring the experiences of ED nurses in caring for PWSUD, as
well as providing the perspectives of rural and northern nurses located in northern British
Columbia. The study findings have implications in informing new strategies for caring for
PWSUD in the ED, new programs and services that are aimed at reducing stigma toward and
improving the care of PWSUD.
Despite the many strengths of the study, there are a number of limitations that should
be considered. First, this study has undertaken an in depth exploration of the experiences of
nurses working in three EDs within northern BC. While these sites range in size and context,
the experiences of the participants may not be entirely representative of RNs in the ED
overall and it is possible that other perspectives exist that were not captured within this study.
Further exploration of this phenomenon within the other ED practice settings, such as larger
urban centres or in communities with greater ethnic diversity, may generate further insights.
Second, participants were only interviewed once for this study. It is possible that
conducting interviews over a longer period of time and at multiple intervals may have
yielded different insights. While this is beyond the scope of this program of study, exploring
attitudes and perspectives over time, perhaps in response to education, may further add to our
understanding of the experience of caring for PWSUD.
Overall, the sample size for the study was adequate and thematic saturation was
achieved (Sandelowski, 1995); however, greater diversity in the sample composition with
respect to demographic characteristics and location would have enhanced this study. First,
the majority of the 13 participants were from the urban site (n = 7), and the remaining six
were from the smaller sites, (n = 5 and n = 1). Second, while attempts were made to recruit a

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more varied sample, I was unable to recruit further participants in the smaller study sites
despite ongoing efforts. Third, all the participants were female, and while they had a wide
range of experience in both nursing in general and in the ED, a more gender diverse
perspective is missed. Despite repeated and significant efforts to recruit a more balanced
sample, no male or other non-binary gendered ED nurses volunteered to participate.
Conclusion
Substance use disorders are a health issue that is prevalent in every aspect of health
care. Care provided to PWSUD is often inadequate and gaps in treatment exist for this
vulnerable patient population. EDs can act as a portal of entry to the health care system for
PWSUD and the nurses who work in EDs can act as facilitators to guide PWSUD through the
system. Providing care for PWSUD can be a challenging and occasionally daunting
experience for RNs in ED. This research was able to highlight how the participants not only
experienced this phenomenon, but also how they navigate caring for PWSUD. Nursing is a
caring profession where members strive to assist all clients with their health care needs.
PWSUD have a unique set of needs that remain subject to stigma. Consequently, nurses
working in the ED, particularly in rural settings where the ED may be the only resource for
PWSUD, must have skills and knowledge related to the effective management of the care of
PWSUD.
The research has provided insights into the challenges that RNs face when caring for
PWSUD in the ED setting, the need for resources specifically aimed at improving outcomes
for PWSUD, and the varied attitudes and beliefs that RNs hold with respect to SUD and
PWSUD. This research has several important implications in the planning of management for
PWSUD including: increasing education and training specific to the care of PWSUD in

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tandem with increasing role support; the need for a shift in the culture regarding PWSUD and
SUD in general, and increasing knowledge about and availability of resources for PWSUD in
the community setting. Furthermore, several opportunities for future research were
illuminated, including the need to address the stigma associated with SUD, development of
strategies to manage the dissonance experienced by nurses whose ideals of nursing practice
are not met by the realities of practice, and comparisons of the nurses’ experiences of
providing care to PWSUD in urban versus rural settings.. Furthermore, this study highlighted
a gap in understanding of the conceptual definition of help in the context of SUD among
nurses. Overall, this study addressed an important gap in existing literature and has provided
an in depth look at how nurses experience caring for PWSUD in the ED setting and the
desire of RNs to provide care and to help PWSUD.

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162

Appendix A
Common Substance of Use Summary
Drug name

Street Names

Used by:

Short Term Effects

Long Term Effects

Withdrawal
symptoms

Cannabis

Blunt,

Smoked

Bud, dope
Ganga,

Eaten

Enhanced sensory
perception and
euphoria followed by
drowsiness; slowed
reaction time;
problems with
balance and
coordination;
increased heart rate
and appetite;
problems with
learning and
memory;
hallucinations;
anxiety; panic
attacks; psychosis

Mental health
problems; chronic
cough; frequent
respiratory infections;

Irritability; trouble
sleeping; decreased
appetite; anxiety

Lowered inhibition;
enhances sensory
perception;
confusion;
depression; sleep
problems; anxiety;
increased heart rate
and blood pressure;
muscle tensing; teeth
clenching; nausea;
blurred vision;
faintness; chills or
sweating; sharp rise
in body temperature

Long-lasting
confusion; depression;
problems with
attention, memory and
sleep; increased
anxiety,
impulsiveness,
aggression; loss of
appetite; decreased
interest in sex

Fatigue, loss of
appetite; depression;
trouble concentrating.

Grass,
Green,
Herb, Joint,
Mary jane,
Pot, Reefer,
Sinsemilla,
Skunk,
Smoke,
Trees
Weed
Hashish
Boom
Gangster
Hash
Hemp

MDMA

Adam,

Swallowed

Clarity,

Snorted

Eve,
Lover’s speed,
Peace,
Uppers

163
leading to liver,
kidney or heat failure
and death
Opioids
(prescription)

Varied
depending on
opioid of
choice

Varied
depending
on opioid of
choice

Pain relief;
drowsiness; nausea;
constipation;
euphoria; confusion;
decreased
respirations;

Unknown

diarrhea; vomiting;
cold flashes with
goose bumps; leg
movements

Death

Hallucinogens

Acid,
Angel dust,
Vitamin K

Cocaine/Crack

Blow,

Snorted

Bump C,

Smoked

Candy,

Injected

Charlie,
Crack,
Flake,
Rock,
Snow,
Toot

Methamphetamine

Crank,

Swallowed

Chalk,

Snorted

Crystal,

Smoked

Restlessness; muscle
and bone pain;
insomnia;

Distortion of
perception of time,
motion, colours,
sound, and self;
disrupted ability to
think and
communicate,
recognize reality;
results in bizarre and
dangerous behaviour;
mood disturbances;

Psychotic like
episodes; respiratory
depression;
dysrhythmias;

Narrowed blood
vessels; enlarged
pupils; increased
body temp, heart rate
and blood pressure;
abdominal pain and
nausea; euphoria;
increased energy,
alertness, insomnia,
restlessness; anxiety;
erratic and violent
behaviour, panic
attacks, psychosis;
dysrhythmia;
myocardial
infarction; stroke
seizure and coma

Loss of sense of smell;
nosebleeds; nasal
damage and
dysphagia; infection
and death of bowel
tissue; poor nutrition
and weight loss

Depression;
tiredness; increased
appetite; insomnia;
vivid and unpleasant
dreams; slowed
thinking and
movement;
restlessness

Increased
wakefulness and
physical activity;
decreased appetite;
increased
respirations, heart

Anxiety; confusion;
insomnia; mood
problems; violent
behaviour; paranoia;
hallucination;
delusions; weight loss;

Depression; anxiety;
tiredness

164
Fire,

injected

rate, blood pressure
and temperature;
dysrhythmia

sever dental problems;
intense itching leading
to skin sores from
scratching

Brown sugar,

Injected

China white,

Smoked

Dope,

Snorted

Euphoria; warm
flushing of skin; dry
mouth; heaviness to
hands and feet;
clouded thinking;
alternate wakeful and
drowsy states;
itching; nausea;
decreased respiration
and heart rates

Collapsed veins;
abscesses; cardiac
infections of lining
and valves;
constipation and
stomach cramps; liver
or kidney disease;
pneumonia

Glass,
Go,
Fast,
Ice,
Meth,
Speed
Heroin

H,
Horse,
Junk,

Restlessness; muscle
and bone pain;
insomnia; diarrhea;
vomiting; cold
flashes with goose
bumps; leg
movements

Skag,
Skunk,
Smack,
White Horse

http://www.drugabuse.gov/publications/research-reports/hallucinogens-dissociative-drugs/director
http://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts

165

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166

Appendix C
Literature Matrix
Title

Author

Year

Comorbidity of
mental health and
substance misuse
problems: a review of
workers' reported
attitudes and
perceptions.

Adams

2008

Originating
Country
UK

Community
providers' views of
alcohol problems and
drug problems

Gassman,
Weisner

2005

USA

An analysis of nurses'
views of harm
reduction measures
and other treatments
for the problems
associated with illicit
drug use

Ford

2010

Australia

Study Population
articles

Community health
care providers
from public and
private medical,
mental health
clinics, and
addictions
programs as well
as welfare
criminal justice
clergy private
therapists,
physicians
All Nurses
registered in the
Australian capital
territory

Study
Design
Literature
Review

Outcomes and Measurements

Main Results or Conclusions

Australia = 5 UK = 10; US =3: Secure
forensics; inpatient acute; crises assessment
and treatment; assertive outreach;
combination in and out pt. teams; MH
staffing MH and/or addictions; clinicians.
Focus on comorbidity; those who began in
MH but have had training in Addictions;
All have some MH participants; Mostly
Quantitative with only 2 qualitative papers.

1. Negative attitudes most predominant
in forensics r/t increased security
concerns and policies that forbid use of
increased security which can hinder
therapeutic relationships
2. Contemporary models of care are not
meeting the needs of clients group
(shared models of care showing
promise)
3. Co morbidity
is viewed at difficulty to treat; low
optimism for success; lots of systems
failures
4. identified lack of training as an issue;
3/4 of articles had nursing staff; willing
to work with comorbid patients but lack
of knowledge and skills to know what
to offer them; paucity of training and
structural problems with services
1. Definitions of drug and alcohol
problems varied widely: drugs usually
viewed as worse: focus on the physical
problems.
2. Alcohol was viewed as a genetic
problem, whereas drugs as a social
problem: extremes were focused on
3. Drug problems carried more stigma

Qualitative:
Interviews
with
structured
demographic
data
collection
and open
ended
interview
questions

Definitions of alcohol and drug problems.
Structured questions re: personal and
professional background; current work
situation; caseload; attitudes and beliefs;
experiences working client with alcohol and
other drug problems

Quantitative:
Survey
design

Variables were taken from the National
Drug Strategy Household Survey
(amended) assessing views on regulated
injection rooms; trials of prescribed heroin;
rapid detox therapy, naltrexone; NSP;
MMP; Treatment with drugs other than
methadone

1. Lots of support for abstinence based
measures
2. more support for naltrexone and rapid
detox than for MMP
3. more support for NSP than MMP
4.regulated injection rooms and
prescribed heroin received least support
5. Nurses seemed to hold either an
abstinence based or a harm reduction

167

A survey of substance
use by health care
professionals and
their attitudes to
substance misuse
patients (NHS staff
survey)

Raistrick,
Russell,
Tober,
Tindale

2008

UK

Health care
professionals
across Yorkshire
region of England:
Nurse, Midwives,
health care
assistants, medical
staff in secondary
care services:
psych, A&E, gen
med; liver and
obstetrics

Quantitative
survey
design:
survey
modified
version of
alcohol and
alcohol
problem
perception
questionnaire

demographics; personal substance use;
work related problems of self and
colleagues; attitudes towards substance use
patients; role adequacy; role legitimacy;
positive expectations, self-efficacy

A descriptive study
on emergency
department doctors'
and nurses'
knowledge and
attitudes concerning
substance use and
substance users.

Kelleher,
Cotter

2009

Ireland

Doctors and
nurses working in
emergency rooms
in three university
hospitals in
Ireland

Quantitative
survey
design:
modelled
after SAAS

Collected demographics; current
knowledge; perceived knowledge;
perceived competence; attitudes toward
substance abuse and users; perceived role in
management and frequency of interactions.

ideology
6. compared well with general
population except more supportive of
HR NEP and prescribed heroin, less
supportive of MMP
7. Nurses form views like rest of society
eg: media social norms
8. Identified education and institutional
support as imperative to improving
nurses’ attitudes.
1. Docs more likely to be nondrinkers nonsmokers; females who drank more
heavily. Docs less likely to use drugs
(fewer drugs less frequently
2. Cannabis use most common other
drug not
3. Doctors and health care assistants
differed widely on their views (all
believed themselves to be competent
and confident) nurses held a more
intermediate place
4. low role legitimacy for doctors and
nurses
1. History taking for drug use (outside
tobacco and ETOH) poor
2. Most have daily contact with users
(inadequate management d/t paucity of
services; viewed pt. at hard to manage
3. Although knowledge base scored as
satisfactory, gaps were identified in
ETOH management, benzos,
amphetamines and methadone.
4. Most thought they knew enough
5. Most thought they were moderately
or very competent in ID/assessment/
management of OD; not competent in
specialist services awareness and
referral, brief interventions or
motivational counselling.
6. Most believed that they had a
legitimate role in caring for users in
EDs
7.overall not permissive of drug
use/abuse; had quite strict beliefs
regarding rule for
treatment/intervention; were not overly
stereotypical; almost 1/2 identified
users as unpleasant to work with but

168

Experiences of
substance abusing
suicidal males who
present frequently to
the emergency
department

Spence,
Bergmans,
Strike,
links,
Ball,
Rhodes,
Watson,
Eynan,
Rufo

2008

Canada

From a single
hospital: health
care professionals
in ED and
including nurses
doctors crisis team
workers; security
officers and nonmedical staff
suicidal substance
abusing males in
ED

Qualitative
study

Themes: reasons for presenting; Pt's
behaviour; identification as a repeat visitor;
emergency department experiences

Guilty until proven
innocent: a qualitative
study of the
management of
chronic non-cancer
paint among patients
with a history of
substance abuse

Baldacchino,
Gilchrist,
Fleming,
Bannister,

2010

UK

medical personnel
from addiction
rheumatology and
pain services from
2 NHS boards and
1 GP practice

Qualitative:
interviews
and focus
groups

The interview and focus group schedules
are neither included nor described

Health care
professionals
knowledge and
attitudes regarding
substance use and
substance users

Kelleher

2007

Ireland

Medline, PubMed,
science direct,
Psychlit and
Blackwell
synergy; also hand
searches of
reference lists

Literature
review

Search terms included knowledge, attitudes,
drug abuse/misuse and substance abuse

Health care

Van Boekel,

2014

The

Doctors working

Quantitative

Medical Condition Regard Scale, the used

had high confidence that they could be
helped
1. Pt.’s were often made to present by
family of HCP: ED identified as not an
appropriate place as too stressful
2. Pt.’s felt like bad behaviour sped up
process: ED staff finds it difficult to
manage within the constraints of ED
3. Staff and pt. describe negative
experiences; staff feel like there is little
they can do and that the patients block
beds; some empathy was evident in the
comments
4. belief that long term goals of these
men cannot be met in ED and realistic
goals need to be set
1. Most doc view opioids as a last resort
for CNCP and are even more reluctant
to give it to PWSUD due trust issues;
misuse; re. addiction; not to be seen as
feeding a habit; too much temptation
2. Docs were able to identify that their
decisions were not always 100%
sensible but they worry that addicts are
exaggerating their pain (there is this
idea re circle of discomfort again)
3. Pain specialists were more trusting
and willing to treat subjective
description of pain but they too looked
for red flags (lost prescriptions, early
refills, doc/pharmacy shopping
1. There were few articles that
addressed trauma or emergency care
2. HCP find substance using patients
unpleasant and difficult to work with
3. Nurses tend to hold
moralistic/stereotypical/pessimistic
views
4 .Barriers to the ID of SUD are time
and knowledge base deficits
5. Pessimistic views may inhibit
willingness to receive education
6. Negative attitudes in general
population may influence HCP which
then impacts the care of SA patients
7. More education in training programs
is needed
1. Regard did differ between 3 sectors

169

professionals regard
towards working with
patients with
substance use
disorders:
Comparison of
primary care, general
psychiatry and
specialist addiction
services

Brouwers,
Weeghel,
Garretsen

Knowing how to play
the game:
hospitalized
substance abusers'
strategies for
obtaining pain relief

Morgan

Mental Health
professionals'
attitudes to drugs and
substance abuse

Pinikahana,
Happell,
Carta

Netherlands

in general
psychiatry HCP;
primary care
physicians and
HCP in addictions
specialty areas

the Attribution questionnaire and the
Attitudes and Beliefs about Alcoholism and
Alcoholics Questionnaire

2006

USA

users 14 male and
4 female; 16 white
and 2 AA; 32-60
years old; all
levels of education
and employment;
majority had use
related infections;
1/3 had HIV; 72%
had Hep C; all
poly drugs; 16
heroin users
2 focus groups
with RN staff

qualitative
grounded
theory

depth of questioning changed as interviews
progressed constant comparison

2002

Australia

Health care
professionals
working in
Melbourne

Quantitative
survey
design

Questionnaire based on SAAS. 46% return
rate

addiction had highest and GP's had
lowest regard ; sector explained only
40% of variance; attribution beliefs,
emotional response and professional
characteristics explained a further 57%
2. GP viewed addiction as a character
flaw and felt more pity, addictions
services felt less anger.
3. Socially desirable answering
associated with regard so regard may be
overestimated
4. Feelings of role legitimacy may
impact level of regard and or impact
attitudes toward SA
Core Categories "knowing how to play
the game":
Sub
Categories "feeling/not feeling
respected" and "strategizing for pain
relief"
Respect and being believed and worked
with to achieve good pain control were
themes that arose. Patients identified a
knowledge deficit among the nursing
staff.
Staff felt inadequate (also indicative of
knowledge deficit); they would prefer
not to work with this group;
patients expected negative reactions
from health care professionals related to
their drug use.
Permissiveness: 59.6 no cannabis
legislation;; 73% disagreed with pot as
healthy teen experimentation; 66.7
disagreed with legalizing use in
personal homes; 75% disagreed with
daily pot use as not harmful; 93.1
disagreed with smoking in school;
76.1% disagreed with people getting no
parole for selling drugs; 59.6 disagreed
with lifelong abstinence for addicts;
72.7 agreed with normal for teen to
experiment; 81.5 agreed parents should
teach safe alcohol consumption
Treatment Interventions: 82% agree
docs diagnosis early of ETOH increases
chance of treatment success; positive
views on family involvement in
treatment; urine drug screens, group

170

Student nurses
attitudes to illicit
drugs: a grounded
theory study

Harling,
Turner

2012

UK

Student nurses at a
school of nursing
in UK

Qualitative:
grounded
theory

Literature review was combined with
results and showed a number of categories
including society, the media, culture,
individual level, practice environment and
nurse education as influencing student
attitudes

Nurses Knowledge
attitudes and beliefs
regarding substance
use: A questionnaire
survey.

Happell,
Pinikahana,
Carta

2002

Australia

Nurse in Victoria

qualitative
survey
design based
on SAAS

Knowledge: most answered all questions in
this area correctly except for dx of SA.
Skills and regular practice: 24.6 thought
dual dx patients adequately managed; 43%
saw DD daily; most took substance use
history for patients 37.4 took tobacco
history for patients.
Perceived knowledge and confidence:
62.7% moderately knowledgeable 2307
very knowledgeable

Stigma reported by
nurses related to those
experiencing drug and
alcohol dependency: a
phenomenological
Giorgi study

Love,
Barr

2009

Australia

Homogenous
group from one
unit n=6 all
Caucasian, 35-58
years of age RN
8m -20y
experience

qualitative 2
unstructured
with more
structured
subsequent
interviews
with

See article for excerpts

therapy, long term outpatient treatment
and paraprofessional counselling
Non-stereotyping: 87.3 disagreed
with people using pot not respecting
authority; 90.7 disagreed with clean
shaven short haired people likely don't
imbibe; 67.6% disagreed that pot leads
to mental illness; 72.9 disagree that all
heroin use leads to dependence; 78.5%
disagree that weekend use= drug
misuse; 79.1 disagree that hospital is
best place to treat; 6406 disagree that
recreational drug use = misuse
Moralism: most disagreed with all
moralism statements
Final Grounded Theory: 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 might 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.
Rn's had adequate knowledge related to
ETOH and other drugs and basic
knowledge re OD heroin and ETOH
dependence. Did not adequately manage
due to lack of training and paucity of
services
Many nurses routinely took ETOH and
SA history
Nurses need training in ID of SUD;
management of ETOH and SUD detox;
management of DD clients
Three main themes:
1. inappropriate judgements from other
units RN's
2. The importance of advocacy:
enhanced privacy/safety; they are
allowed to relapse and still receive
support

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concurrent
collection
and analysis
Physicians beliefs
about the nature of
addiction: a survey of
primary care
physicians and
psychiatrists

Lawrence,
Rasinski,
Yoon,
Culin

2013

USA

American GP's
and Psychiatrists

Quantitative:
Survey
design

Two version of the questionnaire
1. In your judgment, to what extent is
alcoholism each of the following a disease,
a response to psychological wound, a result
of moral failings.
2.
same question with drug addiction rather
than alcoholism

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

Van Boekel,
Brouwers,
Weeghel,
Garretsen

2013

Netherlands

N/A

Systematic
Review

Australia n=12; UK n=7; USA n=5 Canada
n=1; Ireland n=1; One cross country
comparison of 8 EU countries and I
USA/UK. Nurses N=8 MH&A N=7
physicians N=4; 5 also included pts. 20
Quantitative with SAAS and AAPPQ being
prominent. % had interviews or focus
groups 2 Had implicit association tests and
2 had direct observation.

3. Education: SUD inadequately
addressed by general RN's -inadequate
specific education in nurses training need more
Psychiatrists more likely to believe
addiction is a disease. 64% vs 56% of
GP's answered a lot. Type of disease
marginally significant (alcohol more
that drugs) 31% or GP's and 27% of
Psych said a lot to addiction as a
response to psychological wound. 7%
of GP's and 4% of Psych said moral
failings (Psych more likely to say not at
all to moral failings)
42% gave priority to disease model,
31%rated disease model as the same as
another model and 16% prioritized
another model over the disease model
1. HCP found generally to have
negative attitudes toward SA and users regard was lower compared with other
PT groups - HCP unable or unwilling to
empathize- MH&A may have more
positive and optimistic views. Also
those with more experience in working
with addicts had more positive attitudes.
2. Reasons for negative attitudes: pts are
more challenging and may be unsafe:
perceived as violent manipulative,
aggressive, rude, irresponsible and
poorly motivated. Causal attribution
beliefs play a role in how attitudes are
formed; HCP often feel they have a lack
of knowledge and training in dealing
with this group of pt. - Contextual
Factors: time, organizational policy,
role legitimacy, role support accessibility of support structures for
addicts. Education only effective in the
presence or role and organizational
support.
3. Impact of negative attitudes:
Increased stigma = decreased treatment
completion: pts judged HCP as better if
were more positive: One found no
correlation b/w attitude of HCP and
satisfaction with care: some found
negative attitudes = decreased pt.

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Physician Beliefs
about substance
misuse and its
treatment: findings
from a US survey of
primary care
physicians

Johnson,
Booth
Johnson, P.

2005

United
States

Docs from 5
specialties GP
Internal medicine;
obgyn; peds and
family practice

Quantitative:
telephone
survey

Perceived prep to dx hypertension, diabetes,
depression, misuse of prescription drugs,
alcoholism and illegal drugs: perceived
difficulty in discussing depression, alcohol
use and prescription drug misuse; perceived
effectiveness of available treatment
methods for hypertension, diabetes,
depression, smoking
cessation(adults/adolescents), alcoholism
and illegal drug dependency

The determinants of
nurses therapeutic
attitudes to pt. who
use illicit drugs and
implication for
workplace
development

Ford,
Bammer,
Becker

2008

Australia

All Nurses
registered in the
Australian Capital
Territory

quantitative
survey
design

Measures: therapeutic attitude Using
AAPPQ (adapted to include illicit drugs);
personal characteristics (age sex, education,
religion, personal use of substance)
Personal practice factors (role requirements
workplace factors.)

The Dissonant care
management of illicit
drug users in medical
wards, the views of
nurses and patients: a
grounded theory
study

Monks,
Topping,
Newell

2012

UK

purposive
sampling; RN'
from a large NHS
hospital in
northern England
MAUs and
medical wards

qualitative:
grounded
theory

concurrent analysis and collection using
semi structured interviews: see article for
interview schedule:

empowerment; decreased quality of
care provided and decreased HCP-PT
collaboration.
Primary care physicians do not see
themselves as very capable of dx and
treatment of substance use conditions
many also have problems discussing
these problems.
Don't
ask b/c pts lie re abuse (57%), time
constraints (35.1%), questioning pt.
integrity (25%) uncertainty re available
treatments (15.7), personally
uncomfortable (12.6%), not being
reimbursed for the extra time (10.6%).
Authors state some of the responses
show a lack of knowledge re substance
abuse treatments; leads them to not
improve diagnostic skill re substance
abuse and not to engage in
uncomfortable discussions re substance
abuse. Modification of physicians’
beliefs is necessary!
65% agreed role legitimate; 44%
believed in their own performance in
role; role adequacy and satisfaction
were lower;
All professional practice fields
influenced attitude; attitudes toward
illicit drugs significant in predicting
therapeutic attitudes; personal
characteristics not significant;
role support had the biggest impact on
therapeutic attitude - education without
role support was shown to be
ineffective
Recommendations were there needs to
be a focus on preparation and support in
workplace in managing substance
abusers in acute care settings; role
support is crucial = someone to help
resolve personal and clinical issues.
Core Category: Dissonant care
management/delivery: Sub categories
were lack of knowledge to care and
distrust and detachment
lack of education in nursing programslack of confidence in ability outside
physical needs- inadequate care

173

convenience
sampling of users

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

Ford,
Banner,
Becker

2009

Australia

All Nurses
registered in the
Australian Capital
Territory

the point at which role support potentiates
the effect of workplace education and the
benefit gained from increasing the level or
roles support and the event that workplace
education is high

subsample of All
Nurses registered
in the Australian
Capital Territory

Quantitative:
multi
variable
regression
analysis
based on
results from
a survey of
all RN's in
ACT
qualitative
one open
ended
question

Interpersonal
challenges as a
constraint on care: the
experience of nurses'
care of patients who
use illicit drugs

Ford

2011

Australia

Hospital nurses
attitudes toward
patients with a history
of illicit drug use

Chu,
Galang

2013

Canada

IMU nurses at St
Michaels Hospital
in TO ON All full
or part time nurses
invited

Quantitative
used the
DDPPQ
(Pencil and
paper)

Job satisfaction; role specific self-esteem;
role adequacy; role legitimacy; role support

describe any factors that impede your
ability to provide nursing care to patient
who use illicit drugs

delivery (nurses and patients recognized
this) negative opinions were expressed
re pt. group. Pts saw this as threat to
their care and an opportunity for
exploitation. This helped lead to that
cycle of lack of education to inadequate
care provision to behavioural
consequences from pts who are
concerned re their care - detachment of
nurses from these pt. and their care - no
interest in increasing knowledge or
understanding from nurses - inadequate
care delivery and so on
Nurses mistrust pt.'s and pt.'s mistrust
nurses; nurses found pts emotionally
draining and they had difficulty seeing
the person behind the patient
Workplace education is ineffective with
role support is low Moderate level or
role support ae necessary to make
education effective in impacting nurses'
therapeutic attitudes: education can
serve to highlight the complexities of
providing nursing care to substance
abusers and without role support this
can lead to lower confidence levels and
disengagement from the patient.
Interpersonal challenges as an
impediment to care: these included
violence manipulation and
irresponsibility of or from the patient
who uses illicit drugs.
Could lead to further disengagement
form the already marginalized group;
there are limited research studies on
pt.’s responses to care author advocates
for harm reduction approach the focus
of which is to accept the patient
circumstances and move forward
Nurses on this unit held a basically
neutral view of illicit drug users: this
differed from many previous studies,
they did cite poor role support; drug use
is influenced by local economy, HC
system and: outlined limitations
including small and specific sample (1
unit in inner city to) suggested
researching attitudes across HC

174

Inpatient staff
perceptions in
providing care to
individuals with cooccurring mental
health problems and
illicit substance use

Howard,
Holmshow

2010

UK

all in patient
workers from one
sector of MH trust
invited = one
assessment and
admissions unit, 5
mental health
treatment units
and three rehab
units

mixed
methods

DDPPQ scores, whether training re addicts
had been given

Illicit Drug users in
Northern Ireland:
perceptions and
experiences of health
and social care
professionals

McLaughlin,
Mckenna,
Leslie,
Moore,
Robinson

2006

Northern
Ireland:
hospital
and
community
care
workers

Health and social
care professionals

Qualitative:
Focus groups
and
interviews
Appears to
be
qualitative
description

what has been your experience working
with PWSUD? Do PWSUD differ from
other clients you see? How?
Criminalization impact on drug use
affecting care and treatment? Who should
care for DU? Training adequate? What are
your needs? How do you think IDU
perceive HP? Are there any other issues you
would like to discuss?

institutions and geographic settings.
Survey showed that profession had no
significance on DDPPQ score but
training did (those with training had
lower scores). They did identify that
more role support would be good
Interview results: 7 themes a) working
with illicit substance users: identified
how it differs from caring for non-illicit
drug users: safety and engagement b)
team attitudes c)communication and
problem solving in multidisciplinary
meetings: to adapt consistent
approaches; trust policies and local area
protocols: especially around tolerance
to use e) concerns over legality f)staff
support structures f) training
Health care professionals don’t want to
work with users d/t fear or perceived
lack of training: feel like users are
manipulatives. Avoid education that
might draw addicts to you as a provider.
Pessimism about the care and treatment
(negative expectations. No one thought
only primary care providers should take
sole responsibility for drug user; should
be specialists or at best shared care
model.
Many held negative views; many
admitted to limited knowledge and skill
in caring for DU; most professionals
thought specialist only should care for
DU; a lack of empathy was apparent.

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Appendix D
Letter of Invitation to Participate
[Date]
Title of Study:

What are the experiences of Registered Nurses caring for people with
substance use disorders in an emergency department setting?
Student Investigator: Gwen Keeler, MScN Student, School of Nursing ,
University of Northern British Columbia
Faculty Supervisor: Dr. Davina Banner Lukaris, PhD RN, School of Nursing, University of
Northern British Columbia
Faculty Supervisor: Linda VanPelt, MScN, FNP, School of Nursing, University of
Northern British Columbia
I, Dr. Davina Banner-Lukaris, PhD, RN, from the School of Nursing, University of Northern
British Columbia, invite you to participate in a research project entitled “What are the
experiences of Registered Nurses caring for people with substance use disorders in an
emergency department setting?”
The purpose of this research project is to explore how nurses experience caring for people
with substance use disorders and produce a description that is representative of the combined
experiences shared with the researcher. Should you choose to participate, you will be asked
to participate in a telephone interview and to review the transcripts prior to analysis of the
data.
The expected duration of the interview is 60-90 minutes, once and then to review the
transcripts and provide feedback to the researcher on accuracy.
This research should highlight the barriers and opportunities nurses experience in providing
people with substance use disorders with excellent care in emergency room settings. It will
also offer a baseline understanding of how nurses experience caring for this marginalized
group. My hope is that through this research, understanding will be developed so that further
research into related topics can be planned that will allow us to begin to change practices in
order to better serve the population. There is much socially undesirable behaviour associated
with substance use and perhaps improved access to care can decrease the impact of these
behaviours on the public. Furthermore, it is an area that has not been well researched and the
results of the study will add to the nursing body of knowledge
If you have any questions, please feel free to contact me (see below for contact information).
Thank you,
Dr. Davina Banner-Lukaris
Dr. Davina Banner-Lukaris

176

PhD., RN, Principal Investigator
250-960-5852
davina.banner-lukaris@unbc.ca
Gwen Keeler,
BScN, RN, Student Principal Investigator
250-960-6752
gwen.keeler@unbc.ca
Linda Van Pelt
MScN, FNP, Faculty Supervisor
250-960-52
linda.vanpelt@unbc.ca
This study has been reviewed and received ethics clearance through University of Northern
British Columbia’s Research Ethics Board and through Northern Health Application for
Operational Approval in a harmonized certificate of approval E2016.0622.052.00.

177

Appendix E
Participant Demographic Information
Interviewee Gender

Age
(Years)

Place of
Employment

Years as
an RN

Years in
ED

Level of
Education

1.

Female 55-65 (57)

Site 2

35

27

Diploma

2.

Female

45-55 (53)

Site 3

30

30

Diploma

3.

Female

25-35 (30)

Site 2

8

7

Degree

4.

Female

55-65 (57)

Site 2

35

9

Degree

5.

Female

25-35 (35)

Site 1

4

8 months

Degree

6.

Female

35-45 (44)

Site 2

23

21

Degree

7.

Female

35-45

Site 2

19

10

Diploma

8.

Female

25-35 (28)

Site 2

2

1.5

Degree

9.

Female

35-45

Site 2

22

12

Degree

10.

Female

45-55

Site 1

33

27

Degree

11.

Female

45-55

Site 1

26

14

Degree

12.

Female

25-35

Site 1

3

4

Degree

13.

Female

35-45

Site 1

22

7

Degree

178

Appendix F
Interview Schedule
Demographic
information

Experiences

Role Legitimacy












Address consent and that the interview is being recorded.
Age
Gender
Place of employment
Years of experience in the ED
Years of experience as an RN
Level of education



Can you give me a specific example?



What do you see as the critical care nurse’s role in the care of people
experiencing SUD?
What supports do you have to manage people experiencing SUD in the ED
Can you give me an example
Is there anything you don’t have that you wish you did?





Describe your experiences caring for people experiencing SUD in the ED
What is Helpful/Unhelpful

When a person comes in with issues associated with SUD, what do you see as the focus of
care? How does the reality of experience measure up to your ideal.

Training/Education






What training do you have to manage people experiencing SUD in the ED?
Is this training adequate
What is helpful/unhelpful



Is there anything I haven’t asked that you think is important