Substance use practice is a complex and fast-evolving field. Worldwide, we are noting upward trends in substance use (United Nations Office on Drugs and Crime, 2019) and seeing new issues emerge, including deadly overdose crises fueled by synthetic opioids (i.e., fentanyl) and overprescribing (Belzak & Halverson, 2018). Moreover, increases in alcohol and tobacco consumption (Peacock et al., 2018), as well as misuse of prescribed substances such as opioids, sedatives, stimulants, and anxiolytics among adolescents and young adults are also rising (Nolan et al., 2018; Siste et al., 2019). However, the level of knowledge on substance use among health care providers continues to be low, and views of people who use substances is overwhelmingly negative (van Boekel et al., 2013). These two phenomena create significant barriers to care for people who use substances and contribute to the suboptimal care they receive (van Boekel et al., 2013). This has been shown to affect health care decisions and utilization among people who use substances, leading to avoidance, delays, and preventable complications (including death) (Biancarelli et al., 2019; Pauly et al., 2015)
In Canada, nursing programs have not kept pace with the growing rates and changing patterns of substance use, nor have they been responsive to current public health crises related to alcohol (Canadian Institute for Health Information, 2017), opioids (Belzak & Halverson, 2018), and methamphetamine (Casey, 2019). As a result, new nursing graduates may not be prepared to face the range of substance-related issues they will encounter in practice in almost every type of health care setting. The lack of attention to substance use education in nursing programs is not exclusive to Canada. This issue has been widely reported by researchers in countries such as the United States, Australia, and the United Kingdom (Smothers et al., 2018). To get a sense of the current state of substance use education in nursing programs in Canada, we designed a survey to capture nursing students' perspectives on the substance use education they are receiving in their programs. We also wanted to get a sense of content areas being covered, student self-reported preparedness to practice, their exposure to harm reduction as a philosophy of care, and their general understanding of harms associated with commonly used substances. This is the first survey of its kind in the Canadian context and an important addition to a small body of literature on student experiences and the nature (and extent) of substance use education in nursing.
Initially, we conducted a literature search to identify tools that could help guide the development of our survey. Three tools were found to be relevant, namely the Drug Problems Perceptions Questionnaire (Watson et al., 2007), the survey questionnaire developed by Ford (2010) to analyze Australian nurses' views of harm reduction measures and other treatments, and the Harm Reduction Inventory (Jourdan, 2009). Using these tools as a starting point, we extracted sections that were deemed relevant, modified them, and drafted a preliminary survey. We then asked a range of content experts for their feedback, including nurses with experience working with people who use substances, researchers, and nursing students. In light of their feedback, the survey was revised, and the language used was adapted to reflect best practices. For example, people or clients who use substances replaced the terms drug user(s) or drug addict(s). We also changed the term drug or drugs to substance or substances. The final survey included a front page with clear directives; definitions of legal, illegal, and prescribed substances; and five sections to be completed. Students were asked to answer the questions based on what they had learned so far in their program. No distinction was made between clinical or classroom learning. The five sections focused on:
- Profile of participants: Six questions including age, location, year in the nursing program, clinical areas of interest, hours of substance use education, and exposure to people who use substances in clinical experiences.
- Role preparation: A set of four questions taken from the 30-question Drug Problems Perceptions Questionnaire (Watson et al., 2007). Participants were asked to answer this set of questions for three categories of substances (legal, illegal, and prescribed) using a 5-point Likert scale.
- Content areas: Inspired by Ford's (2010) survey format, we identified 22 content areas deemed essential to provide safe, competent, ethical care to people who use substances and measured each one using a 5-point Likert scale.
- Opposing statements: 11 opposing statements were adapted from the Harm Reduction Inventory (Jourdan, 2009) to assess if harm reduction, as a philosophy of care, was embedded in what students had learned so far in their programs. Some of the statements were modified to reflect the Canadian context (e.g., cannabis is now a legal substance in Canada).
- Ranking of substances: Students were asked to rank six substances from the least harmful to the most harmful based on what they had learned in their programs to date (i.e., heroin, cocaine, alcohol, cannabis, methamphetamine, and tobacco).
Following ethics approval, a survey invitation was sent to the Canadian Nursing Students' Association, which was then forwarded to their student members (N = 30,000) and posted on their social media platforms. The survey invitation was also shared with members of the Harm Reduction Nurses Association. The survey was opened on October 7, 2019, and closed on November 7, 2019, to ensure that it would not conflict with the beginning and end of the fall term. Reminders were sent out over the course of that month to encourage students to participate. Survey completion took on average 10 to 15 minutes. Students who completed the survey were eligible to enter a draw for a $100 gift card. Names and email addresses of students who entered the draw were kept separate and could not be linked to their survey responses.
A total of 329 students completed the survey. Overall, the majority of participants were ages 18 to 34 years old (92%) and they were equally distributed across the 4 years of the nursing program, with 21% of survey participants in first year, 27% in second, 22% in third, and 30% in fourth. The provinces most represented were British Columbia (n = 120, 36%), Ontario (n = 99, 30%), Alberta (n = 33, 10%), and Nova Scotia (n = 34, 10%). When asked to list areas where they wished to work after graduation, a majority listed acute care or general medicine (67%), followed by public health, community health, or out-reach (55%), and mental health (26%). When asked how many hours of substance use education they had received in their program to date, 43% of participants responded 1 to 5 hours and 20% none.
To explore role preparation, we asked participants to indicate to what extent they agreed with four statements:
- I feel I have working knowledge of these substances and their related problems.
- I feel I know enough about the physical and psychological effects of these substances to carry out my role as a nurse.
- I feel I know enough about these substances to carry out nursing assessments and interventions.
- I feel I can appropriately advise my patients/clients about these substances and their effects.
More specifically, we asked them to apply these statements to three categories of substances: legal substances including tobacco, cannabis, and alcohol (including non-beverage alcohols such as mouthwash, hand sanitizer, and hairsprays) (response rate = 95%); illegal substances such as crack, cocaine, heroin, methamphetamine (response rate = 93%); and prescribed substances that are commonly misused such as opioids, sedatives, stimulants, and anxiolytics (response rate = 91%).
Results suggest that nursing students tend to have more working knowledge of legal and prescribed substances than illegal ones; 60% agreed or strongly agreed that they had working knowledge of legal substances, and 50% agreed or strongly agreed that they had working knowledge of prescribed substances; however, only 25% reported having working knowledge of illegal substances, and 54% felt they did not have working knowledge of illegal substances. We see a similar trend in knowledge of the physical and psychological effects of substances, with just under half of students reporting they knew enough about legal (46%) and prescribed (45%) substances to perform their role as nurses. In contrast, only 18% of students felt they knew enough about the physical and psychological effects of illegal substances to perform their role.
When it comes to being able to carry out nursing assessments and interventions, answers were split equally between students who felt they had enough knowledge (legal substances: 40%; prescribed substances: 42%) and those who did not (legal substances: 36%; prescribed substances: 36%). Again, the majority of students (64%) did not feel they had sufficient knowledge of illegal substances to perform nursing assessments and interventions. Additionally, 64% did not feel they could appropriately advise clients about illegal substances and their effects. Although slightly better for legal and prescribed substances, our results point to gaps, with 36% of students reporting they could not appropriately advise clients about legal substances and 40% reporting they could not appropriately advise clients about prescribed substances.
To get a sense of what students are learning in their nursing programs, we asked participants to determine the extent to which they had learned about 22 content areas (response rate = 89%). After adding content areas rated 3 (somewhat covered), 4 (covered), and 5 (covered extensively and comprehensively), we found only seven content areas that exceeded a 50% benchmark. In other words, 50% or more students identified that the following content areas was at least somewhat covered in their program
- naloxone kit distribution and education (74%)
- signs and symptoms of withdrawal (72%)
- stigma and discrimination experience by people who use substances (71%)
- overdose prevention and management (61%)
- role and responsibilities when caring for people who use substances (56%)
- sterile supply distribution (53%)
- supervised consumption services (53%)
To perform an assessment of content areas that were the least covered in nursing programs, we used a similar approach and the same benchmark. Fifty percent or more students identified that the following content areas were not covered in their program
- Drug-checking services (74%)
- Care of youth (74%), as well as care of women and newborns (73%)
- Use of the Clinical Institute Withdrawal Assessment for Alcohol Protocol, or CIWA (72%)
- Discharge teaching (71%)
- Rights of people who use substances (67%)
- Vaping for nicotine and cannabis use (66%)
- Treatment using prescribed diacetylmorphine and hydromorphone (66%)
- Support for families (65%)
- Managed alcohol programs (63%)
- Treatment using prescribed methadone and suboxone (56%)
- Pain management for people who use substances (56%)
- Use of the Clinical Opiate Withdrawal Scale, or COWS (53%)
When asked to select between 11 opposing statements (response rate = 98%), the majority of students selected the statements consistent with a harm reduction philosophy. Our results indicate that when students are learning about substance use, they are learning about harm reduction or, at the very least, that they are learning about content informed by a harm reduction philosophy or coming into programs with values that align with that philosophy. However, we noted a few instances in which approximately one quarter of participants selected statements that ran counter to a harm reduction philosophy.
Finally, we asked participants to rank six substances from the most harmful to the least harmful. The goal of this question was to capture whether student perception reflects the current state of evidence of the harms of each substance, specifically heroin, cocaine, alcohol, cannabis, methamphetamine, and tobacco. Illegal substances were perceived as the most harmful while legal substances were less harmful, with cannabis reported as the least harmful of the six.
Our results are consistent with previously published studies that demonstrate that substance use education in nursing programs is largely insufficient and not keeping up with the issues on the ground (Smothers et al., 2018). This has been a long-standing problem in nursing; studies have shown that little change has occurred in the content and amount of substance use education in the past four decades (Finnell et al., 2018). A compelling example from the literature demonstrates this point. Over 30 years ago, Hoffman and Heinemann (1987) conducted a national survey of nursing schools in the United States and found that the majority of schools required only 1 to 5 hours of substance use education. The authors had expressed concern about the mismatch between required hours of substance use education and the increasing prevalence of substance use-related issues that needed to be addressed by the nursing profession. In light of our results, we echo their concerns and renew the call to improve substance use education so that nursing remains responsive to societal needs and to ensure that new nursing graduates are adequately prepared for practice.
Our results also suggest that students feel unprepared to work with people who use substances across all categories (i.e., legal, illegal, and prescribed). It follows that a lack of substance use education would result in poor preparation to practice with people who use substances. However, it is worrisome to see the gaps in knowledge reported by students and their perceived lack of preparation for their roles as nurses. Of particular concern is that students did not feel knowledgeable or prepared to provide care to people who use illegal substances; this needs to be urgently addressed for a number of reasons. One, education is essential to eliminate health care-related stigma, discrimination, and barriers faced by people who use illegal substances. Two, education is key to ensure that people who use illegal substances have access to safe, competent, and ethical nursing care. Three, education challenges popular views or myths that nursing students may hold about the use of illegal substances. The results of the ranking section reinforced the importance of challenging such views and myths; although illegal substances can lead to adverse health outcomes, including death, the most harmful substances on a global scale are alcohol and tobacco (Peacock et al., 2018). This was not reflected in the students' ranking—and possibly not in their learning.
Our results revealed that nursing students appear to have some exposure to harm reduction as a philosophy of care, or at a minimum they recognize that the harm reduction philosophy aligns with their overall approach to nursing care. This is an encouraging finding, particularly given the dearth of substance use education students report receiving. However, in contrast, students do not appear to be learning the content that is required to translate harm reduction into practice. For example, what might harm reduction look like when working with pregnant women who use substances? What could harm reduction look like when making a care plan for someone admitted to the intensive care unit who uses alcohol every day? What is a harm reduction approach when working in a school setting? According to our results, these content areas are not being covered in nursing programs. This survey is an important reminder that students should feel knowledgeable and equipped to implement harm reduction with people who use all types of substances. Failing to offer them concrete ways of performing harm reduction may therefore result in little harm reduction being done in practice—particularly as harm reduction interventions can be challenging to implement in rigid clinical environments such as the hospital, which is where the majority of nursing students will practice following graduation.
In light of our results and gaps highlighted in the nursing literature, the following steps should be considered to improve substance use education. First, a four-pillar approach should be adopted to ensure that substance use education is built on clear conceptual underpinnings, consistent with empirical evidence, responsive to practical realities and needs, and informed by harm reduction principles. Second, a framework of entry-to-practice competencies that reflects the range and complexity of substance-related issues nurses encounter in practice should be developed, along with a detailed process for incorporating these competencies into existing “overcrowded” nursing programs (e.g., Finnell et al., 2018). Third, creative ways of closing the gaps in existing programs should be prioritized over slow, time-consuming, and resource-intensive structural changes to the curriculum. This means looking for missed opportunities within existing programs, incorporating content across learning environments, making full use of technology, simulation, and other tools, and implementing interventions shown to be effective at providing content and changing student attitudes. Finally, the expertise of people with lived and living experience of substance use should be given a central role in substance use education. This involves creating space in nursing education for students to learn from people most affected and be exposed to different experiences of substance use.
Our survey presented several limitations, including the small sample size, reliance on self-reported data, and inclusion of students in various stages of their nursing programs. Additionally, it did not include the perspectives of nursing faculty or practicing nurses, nor did it undergo new measures of validity. Nonetheless, our survey revealed interesting findings that can inform current efforts to address gaps in substance use education in Canada. It is our hope that these results support educators advocating for change and prompt nursing organizations to increase their advocacy efforts so that we may remedy decades of neglect in substance use education in undergraduate nursing education. Given the progression and urgency of substance use issues worldwide, nursing programs cannot afford to leave this issue unaddressed.
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