Nursing attitudes and empathy toward patients predict positive patient experiences (Sinclair et al., 2017; Vaismoradi, Jordan, & Kangasniemi, 2015). Studies have shown that nurses can have negative attitudes toward patients with substance use disorder (SUD) and that these attitudes contribute to suboptimal care (Monks, Topping, & Newell, 2013; Morgan, 2014; van Boekel, Brouwers, van Weeghel, & Garretsen, 2013, 2014). These negative attitudes also have been noted among nursing students (Lewis & Jarvis, 2019; Williams, Boyle, & Fielder, 2015). SUD is the recurrent use of alcohol, drugs, or both that causes significant clinical and functional impairment (American Psychiatric Association, 2013). SUD is a prevalent health problem with high morbidity and mortality, as well as frequently co-occurring health disorders (Compton, Thomas, Stinson, & Grant, 2007; National Institute on Drug Abuse, 2014). The recent increased use of illicit drugs (Jayadevappa, Chhatre, & Metzger, 2015; National Institute on Drug Abuse, 2015) makes the issue of negative nursing attitudes and low empathy timely and pressing.
Nurses in acute care settings often care for patients with SUD and their comorbid conditions. However, health care providers generally do not consider themselves adequately trained to care for patients with SUD (Monks et al., 2013; Ross et al., 2015; van Boekel et al., 2013) and perceive these patients as dangerous (Neville & Roan, 2014). Together, these attitudes and perceptions lead to reduced time spent caring for patients with SUD (van Boekel et al., 2013).
Nursing students enter into their professional education with higher empathy than students who choose other majors (Penprase, Oakley, Ternes, & Driscoll, 2013), and this empathy level remains high throughout their nursing programs (Lovan & Wilson, 2012). Although one might expect that empathy is sustained in all patient care experiences, the literature has shown that some nursing students harbor negative attitudes toward patients with SUD, suggesting a lowered empathy.
In the current undergraduate nursing education environment, direct clinical exposure to individuals with SUD is often minimal, which may contribute to negative attitudes reinforced by social viewpoints (Harling & Turner, 2012). No study has examined nursing students' attitudes toward and empathy for patients with SUD before and after a senior practicum in which students were likely to provide direct care for this population. Furthermore, no study has examined student perceptions of their educational preparation to work with patients with SUD. The purpose of this study was to examine nursing students' attitudes toward and empathy for patients with SUD before and after a senior mentorship practicum in acute care settings. The research questions guiding this study were:
- Do nursing students' attitudes and empathy toward patients with SUD change after caring for and interacting with them in a senior mentorship practicum?
- Are there differences in nursing students' attitudes and empathy toward patients with SUD across practice settings?
- What are nursing students' perceptions of their educational foundation in caring for patients with SUD?
Mezirow's transformative learning theory (Mezirow, 1978) and the theory of personal system empathy (Alligood & May, 2000) guided this study. Transformative learning theory posits that individuals interpret their own experiences uniquely and shape their view of the world as a result (Cranton & Taylor, 2012). It is possible that nursing students' perceptions toward patients with SUD may be transformed after the mentorship experience. The Alligood and May (2000) theory of personal system empathy holds that “empathy organizes perceptions, facilitates an awareness of self and others, increases sensitivity . . . and cultivates understanding of individuals within a historical and social context, and affects learning” (pp. 245–246). Thus, empathy entails understanding the patient's feelings and circumstances to establish a therapeutic caring relationship to provide effective care. It was anticipated that after the mentor-ship practicum, nursing students might develop enhanced empathy for patients with SUD that could influence their perceptions.
Study Design and Participants
A multimethod descriptive design was used to examine nursing students' attitudes and empathy before and after a senior mentorship practicum. After receiving Institutional Review Board approval, 93 nursing students enrolled in a senior mentorship practicum course were invited to participate in the study through e-mail and a class announcement. The nursing students were scheduled to work one-on-one with a professional nurse for 120 hours in a variety of practice settings (i.e., medical-surgical, telemetry, maternal-child, emergency department, and intensive care unit). A power analysis for paired t test demonstrated that a minimum of 51 participants would be needed (based on a power of .80, an alpha level of .05, and a medium effect size of f = .25). Nursing students who agreed to participate were asked to complete the instruments before and after the mentorship practicum using a secure Internet survey program (Qualtrics™).
A total of 25 nursing students participated in one of seven focus groups that were held and moderated by the principal investigator (M.S.S.), who guided the discussion with open-ended questions with the goal of eliciting students' perceptions of caring for patients with SUD and their perceived educational preparation to care for this population. Focus groups were limited to a maximum of four nursing students to ensure that all individuals had an opportunity to express their thoughts fully (Kreuger & Casey, 2015). Each focus group was audiorecorded and subsequently transcribed. All of the nursing students who completed the pre- and postsurveys were offered a $25 gift card to a local retail store. No additional honorarium was offered to students who participated in the focus groups.
The Jefferson Scale of Empathy (JSE) was used to measure student empathy. The JSE is a 20-item instrument with a 7-point Likert scale format. It was created to measure empathy among physicians (Hojat et al., 2001). The JSE has been modified and used in nursing education with a reliability coefficient alpha of .77 (Ward et al., 2009). Higher scores indicate higher empathy.
The Drug and Drug Problems Perceptions Questionnaire (DDPPQ) is a 22-item instrument with a 7-point Likert scale format. This questionnaire measures attitudes of professionals working with individuals who use substances. A higher score indicates a more negative attitude. Reliability and validity of the DDPPQ have been established in use with health professionals with support for internal consistency based on a reported alpha coefficient of .87 (Watson, Maclaren, & Kerr, 2007). The DDPPQ tool has been used by Harling (2017) to assess nursing student attitudes toward patients who use illicit drugs.
An investigator-developed demographic questionnaire elicited information about participants' characteristics. Focus groups were led and moderated by the principal investigator (M.S.S.), who guided the discussion with open-ended questions to elicit nursing students' perceptions of their experiences of working with patients with SUD. Focus groups were limited to four students to ensure that all participants had an opportunity to express their thoughts fully (Kreuger & Casey, 2015). Each focus group was audiorecorded and transcribed.
To examine changes in pre- and posttest scores, paired t tests were performed. ANOVA with a Bonferroni post hoc test was completed to examine differences between baseline and post-mentorship scores among groups (i.e., emergency department, intensive care, medical-surgical, telemetry, and maternal-child). Transcripts from focus groups were analyzed using Colaizzi's (1978) phenomenological reduction. Transcripts were read and re-read, then coded a priori for themes related to attitudes, empathy, perceptions, and educational preparation, as well as any additional themes. Methodological rigor was assured by maintaining an audit trail, reflexivity, and the use of triangulation whereby the principal investigator verified and refined the emergent themes with the second investigator and performed member checking with participants in the focus groups (Polit & Beck, 2017).
Of 93 eligible nursing students, 53 students completed the JSE, DDPPQ, and demographic surveys before and after the focus groups for a 57% participation rate. Of the nursing students who completed the pre- and postsurveys, 22.6% (n = 12) completed their mentorship in a maternal-child setting, 15.1% (n = 8) in an intensive care unit, 18.9% (n = 10) in a telemetry unit, 26.4% (n = 14) in a medical surgical unit, and 17% (n = 9) in an emergency department. The majority of participants were female with an average age of 23.2 years, and the majority of participants (75.5%, n = 40) reported knowing someone who had used or abused substances.
Paired t tests revealed no differences in attitudes or empathy among the nursing students prior to mentorship. Upon completion of the mentorship, empathy scores increased significantly for all of the nursing students (p < .001), and the majority of participants had significantly improved attitudes toward patients with SUD (p < .001; 86.8%, n = 46). ANOVA indicated overall significant postexperience site differences in attitudes and empathy. The Bonferroni analysis of multiple comparisons revealed nursing students who worked in maternal-child settings had significantly poorer attitudes toward patients with SUD compared with nursing students who worked in other settings (p < 0.05). However, there was no significant difference in empathy scores across practice settings. Data from seven focus groups with a total of 25 participants revealed five major themes:
- Lack of educational preparation.
- Transitioning from fear to empathy.
- Generational differences in staff nurses' attitudes.
- Exposure to SUD as a frame of reference and normalcy.
- Feelings of helplessness and blame in maternal-child settings.
Lack of Educational Preparation
The nursing students discussed feeling inadequately prepared to work with patients coping with SUD. Students lamented that they had not been assigned to this patient population by their prior clinical instructors. One nursing student said, “I feel they taught us book stuff but not patient interactions. We need experience…. We need more encounters—especially just talking to them.”
Transitioning From Fear to Empathy
Participants expressed fear of the unknown and not knowing what to expect. They described being afraid that these patients would be “more aggressive.” Over time, this fear was replaced by having a sense of heightened empathy and seeing the human being behind the SUD. One participant said:
They're people, they have a disease.… We need to treat them like every other patient and take them seriously every time they come in. Even if they came in four times this week… this time it could be a real heart attack.
Generational Differences in Staff Nurses' Attitudes
Nursing students in all of the focus groups described numerous incidences when they observed “older” nurses using pejorative terms to describe patients with SUD and in a number of instances when treatment was delayed. The nursing students also observed that “older nurses” treated this population differently than they treated their other patients. One nursing student stated:
It made me frustrated! Absolutely! There were little things that could have been done that didn't happen. You're going to listen to the old lady who broke her hip for like 2 hours but you can't take 5 minutes with the guy who overdosed?
Exposure to SUD as a Frame of Reference and Normalcy
Many of the nursing students reported having a family member, friend, or acquaintance who had dealt with SUD. This exposure provided a frame of reference and to some degree a sense of normalcy in that the nursing students believed anyone can experience addiction. One participant said, “This was very typical with what I grew up around. I had a lot of family that was involved in drugs…. So what I saw was kind of normal behavior for people with that disorder.”
Feelings of Helplessness and Blame by Students in Maternal-Child Settings
Nursing students who completed their mentorship in the maternal-child settings expressed helplessness when caring for infants born with neonatal abstinence syndrome and tended to blame the birth mother with SUD for the negative health effects on infants. The nursing students openly admitted to judging the mothers of infants born with neonatal abstinence syndrome. One nursing student said, “I wish I could say it's no different. It's harder cause you try not to be judgmental. It's frustrating . . . why did they do this to their baby?”
Empathy scores were increased in all practice settings following the mentorship practicum. These findings were supported by the qualitative data as noted above. An interesting finding was that unlike previous studies (e.g., Harling, 2017), the nursing students in this study did not demonstrate negative attitudes toward this population (except in the maternal-child setting). This difference may be due in part because many of the nursing students in this study reported having people in their lives who had experienced some form of SUD. The positive change in attitudes is consistent with the findings of Lewis and Jarvis (2019) who reported that students' comfort level increased over time as the students had more experience with this patient population.
Another contributing factor may be that the perception of drug use has changed significantly in recent decades (Coomber, Moyle, & South, 2016). The United States has transitioned from “a war on drugs” in the 1970s, to “just say no” in the 1980s and 1990s, to the legalization of marijuana in many states in recent years. Generation Y nursing students (i.e., those born between 1995 and 2012) grew up in a time when the focus on substance use was on rehabilitation rather than incarceration. Thus, they may be less likely to stigmatize individuals with SUD compared with nurses who grew up in previous generations.
Students did not feel educationally prepared to work with this patient population. A recent systematic review revealed that any type of SUD education had a positive impact on nursing students' attitudes, knowledge, and skills (Smothers et al., 2018). However, the nursing students in this study were exposed to only approximately 1.5 hours of lecture concerning SUD, which by the students' accounts did not prepare them adequately. Other SUD content embedded in various courses also may not have been recognized by the students. Nonetheless, the data indicate a need for curricula to have greater emphasis on SUD, including nursing interventions. Faculty typically are challenged to fit more content in an already crowded curriculum. Finnell et al. (2018) described a four-phase process for integrating education on SUD into an already busy curriculum, and Nash et al. (2017) described the efficacy of integrating up to 30 hours of SUD education. Given the prevalence of SUD, the need to educate nursing students is critical.
The last theme was students' feelings of helplessness when caring for infants born with neonatal abstinence syndrome (NAS) and their tendency to blame the mother with SUD for the harmful health effects on infants and children. This finding was not surprising. Lewis and Jarvis (2019) reported that nursing students in maternity clinical rotations experienced bias and internal conflict when caring for newborns with NAS. Understandably, caring for infants with NAS can be stressful and challenging for nursing students, thus negative attitudes toward the mothers may result (Romisher, Hill, & Cong, 2018).
One limitation of this study is that it was conducted at one university with a small sample size. Other limitations include the use of a convenience sample, students in the focus groups self-selected, potential bias in the sample, the number of care encounters with patients with SUD was not measured, and no information regarding the age of staff nurses who mentored the students was solicited.
Implications and Conclusion
The positive attitudes and enhanced empathy shown were encouraging and may contribute to quality care. The finding that nursing students in the maternal-child settings expressed more negative attitudes compared with their peers is concerning. Schools of nursing should consider integrating more robust curriculum on SUD in maternity and medical surgical courses in addition to the traditional mental health and psychiatric courses. The curriculum should focus on fostering understanding and empathy for all individuals coping with SUD, and in particular, for childbearing women who suffer from SUD and their infants. These educational interventions should be considered in both the undergraduate curricula as well as the professional development setting.
Generational shifts are another important consideration from the findings. Future research is recommended to examine best educational approaches to help nursing students and practicing nurses to develop therapeutic relationships and provide effective, compassionate care for individuals with SUD. Fostering student preparedness to care for individuals with SUD includes focusing on SUD education and using academic clinical experiences to promote student knowledge, skills, attitudes, and confidence. In addition, as the opioid epidemic continues to grow, the need will only increase for providers who can provide quality nonjudgmental empathic care.
- Alligood, M.R. & May, B.A. (2000). A nursing theory of personal system empathy: Interpreting a conceptualization of empathy in King's interacting systems. Nursing Science Quarterly, 13(3), 243–247. doi:10.1177/08943180022107645 [CrossRef]
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- Colaizzi, P. (1978). Psychological research as the phenomenologist views it. In Valle, R.S. & King, M. (Eds.), Existential-phenomenological alternatives for psychology (pp. 48–71). New York, NY: Oxford University Press.
- Compton, W.M., Thomas, Y.F., Stinson, F.S. & Grant, B.F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States–Results from the National Epidemio-logic Survey on Alcohol and Related Conditions. Archives of General Psychiatry, 64(5), 566–576. doi:10.1001/archpsyc.64.5.566 [CrossRef]
- Coomber, R., Moyle, L. & South, N. (2016). The normalisation of drug supply: The social supply of drugs as the “other side” of the history of normalisation. Drugs: Education, Prevention and Policy, 23(3), 255–263. doi:10.3109/09687637.2015.1110565 [CrossRef]
- Cranton, P. & Taylor, E.W. (2012). Transformative learning theory: Seeking a more unified theory. In E. C. Taylor, P (Ed.), The handbook of transformative learning: Theory, research, and practice (pp. 3–20). San Francisco, CA: John Wiley & Sons.
- Finnell, D.S., Savage, C.L., Hansen, B.R., Sanchez, M., White, K.M., Johnson, J.A. & Seale, J.P. (2018). Integrating substance use content in an “overcrowded” nursing curriculum. Nurse Educator, 43(3), 128–131. doi:10.1097/NNE.0000000000000438 [CrossRef]
- Harling, M.R. (2017). Comparisons between the attitudes of student nurses and other health and social care students toward illicit drug use: An attitudinal survey. Nurse Education Today, 48, 153–159. doi:10.1016/j.nedt.2016.10.012 [CrossRef]
- Harling, M.R. & Turner, W. (2012). Student nurses' attitudes to illicit drugs: A grounded theory study. Nurse Education Today, 32(3), 235–240. doi:10.1016/j.nedt.2011.05.002 [CrossRef]
- Hojat, M., Mangione, S., Nasca, T.J., Cohen, M.J.M., Gonnella, J.S., Erdmann, J.B. & Magee, M. (2001). The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educational and Psychological Measurement, 61(2), 349–365. doi:10.1177/00131640121971158 [CrossRef]
- Jayadevappa, R., Chhatre, S. & Metzger, D. (2015). Trend in substance use admissions among older adults. Drug and Alcohol Dependence, 156, e103. doi:10.1016/j.drugalcdep.2015.07.286 [CrossRef]
- Kreuger, R.A. & Casey, M.A. (2015). Focus groups: A practical guide for applied research (5th ed.). Los Angeles, CA: Sage.
- Lewis, L.F. & Jarvis, L. (2019). Undergraduate nursing students' experiences and attitudes towards working with patients with opioid use disorder in the clinical setting: A qualitative content analysis. Nurse Education Today, 73, 17–22. doi:10.1016/j.nedt.2018.11.001 [CrossRef]
- Lovan, S.R. & Wilson, M. (2012). Comparing empathy levels in students at the beginning and end of a nursing program. International Journal of Human Caring, 16(3), 28–33. doi:10.20467/1091-5710.16.3.28 [CrossRef]
- Mezirow, J. (1978). Perspective transformation. Adult Education Quarterly, 28(2), 100–110. doi:10.1177/074171367802800202 [CrossRef]
- Monks, R., Topping, A. & Newell, R. (2013). The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: A grounded theory study. Journal of Advanced Nursing, 69(4), 935–946. doi:10.1111/j.1365-2648.2012.06088.x [CrossRef]
- Morgan, B.D. (2014). Nursing attitudes toward patients with substance use disorder in pain. Pain Management Nursing, 15(1), 165–175. doi:10.1016/j.pmn.2012.08.004 [CrossRef]
- Nash, A.J., Marcus, M.T., Cron, S., Scamp, N., Truitt, M. & McKenna, Z. (2017). Preparing nursing students to work with patients with alcohol or drug-related problems. Journal of Addictions Nursing, 28(3), 124–130. doi:10.1097/JAN.0000000000000189 [CrossRef]
- National Institute on Drug Abuse. (2014). Medical consequences of drug abuse. Retrieved from https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-drug-abuse-nida
- National Institute on Drug Abuse. (2015). Nationwide trends. Retrieved from https://www.drugabuse.gov/publications/drugfacts/nationwide-trends
- Neville, K. & Roan, N. (2014). Challenges in nursing practice: Nurses' perceptions in caring for hospitalized medical-surgical patients with substance abuse/dependence. JONA: The Journal of Nursing Administration, 44(6), 339–346. doi:10.1097/NNA.0000000000000079 [CrossRef]
- Penprase, B., Oakley, B., Ternes, R. & Driscoll, D. (2013). Empathy as a determining factor for nursing career selection. Journal of Nursing Education, 52(4), 192–197. doi:10.3928/01484834-20130314-02 [CrossRef]
- Polit, D.E. & Beck, C.T. (2017). Trustworthiness and integrity in qualitative research. In Polit, D.F. & Beck, C.T. (Eds.), Nursing research: Generating and assessing evidence for nursing practice (10th ed., pp. 557–575). Philadelphia, PA: Wolters Kluwer.
- Romisher, R., Hill, D. & Cong, X. (2018). Neonatal abstinence syndrome: Exploring nurses' attitudes, knowledge, and practice. Advances in Neonatal Care, 18(2), E3–E11. doi:10.1097/ANC.0000000000000462. [CrossRef]
- Ross, L.E., Vigod, S., Wishart, J., Waese, M., Spence, J.D., Oliver, J. & Shields, R. (2015). Barriers and facilitators to primary care for people with mental health and/or substance use issues: A qualitative study. BMC Family Practice, 16, 135. doi:10.1186/s12875-015-0353-3. [CrossRef]
- Sinclair, S., Beamer, K., Hack, T.F., McClement, S., Raffin Bouchal, S., Chochinov, H.M. & Hagen, N.A. (2017). Sympathy, empathy, and compassion: A grounded theory study of palliative care patients' understandings, experiences, and preferences. Palliative Medicine, 31(5), 437–447. doi:10.1177/0269216316663499 [CrossRef]
- Smothers, L.Z., Reynolds, M.V., McEachern, M.M., Derouin, M.A., Carter, M.B. & Muzyk, M.A. (2018). Substance use education in schools of nursing: A systematic review of the literature. Nurse Educator, 43(3), 136–139. doi:10.1097/NNE.0000000000000449 [CrossRef]
- Vaismoradi, M., Jordan, S. & Kangasniemi, M. (2015). Patient participation in patient safety and nursing input—A systematic review. Journal of Clinical Nursing, 24(5–6), 627–639. doi:10.1111/jocn.12664 [CrossRef]
- van Boekel, L.C., Brouwers, E.P.M., van Weeghel, J. & Garretsen, H.F.L. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1–2), 23–35. doi:10.1016/j.drugalcdep.2013.02.018 [CrossRef]
- van Boekel, L.C., Brouwers, E.P.M., van Weeghel, J. & Garretsen, H.F.L. (2014). Healthcare professionals' regard towards working with patients with substance use disorders: Comparison of primary care, psychiatry and specialist addiction services. Drug and Alcohol Dependence, 134, 92–98. doi:10.1016/j.drugalcdep.2013.09.012 [CrossRef]
- Ward, J., Schaal, M., Sullivan, J., Bowen, M.E., Erdmann, J.B. & Hojat, M. (2009). Reliability and validity of the Jefferson Scale of Empathy in undergraduate nursing students. Journal of Nursing Measurement, 17(1), 73–88. doi:10.1891/1061-3718.104.22.168 [CrossRef]
- Watson, H., Maclaren, W. & Kerr, S. (2007). Staff attitudes towards working with drug users: Development of the Drug Problems Perceptions Questionnaire. Addiction, 102(2), 206–215. doi:10.1111/j.1360-0443.2006.01686.x [CrossRef]
- Williams, B., Boyle, M. & Fielder, C. (2015). Empathetic attitudes of undergraduate paramedic and nursing students towards four medical conditions: A three-year longitudinal study. Nurse Education Today, 35(2), e14–e18. doi:10.1016/j.nedt.2014.12.007 [CrossRef]