“You’re kind of at war with yourself as a nurse”: Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder

Autoři: Gabrielle Horner aff001;  Jeff Daddona aff001;  Deirdre J. Burke aff002;  Judith Cullinane aff003;  Margie Skeer aff001;  Alysse G. Wurcel aff001
Působiště autorů: Tufts University School of Medicine, Department of Public Health and Community Medicine, Boston, Massachusetts, United States of America aff001;  Tufts Medical Center, Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Boston, Massachusetts, United States of America aff002;  Tufts Medical Center, Department of Nursing, Boston, Massachusetts, United States of America aff003
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224335



In the midst of an opioid epidemic, health care workers are encountering an increasing number of patients who have opioid use disorder in addition to complex social, behavioral and medical issues. Of all the clinicians in the hospital, nurses spend the most time with hospitalized patients who have opioid use disorder, yet there has been little research exploring their experiences in caring for this population. The objective of this study was to assess the attitudes, perceptions, and training needs of nurses in the inpatient setting when caring for patients who have opioid use disorder.


One-on-one in-depth interviews were conducted with nurses working at a large academic medical center in Boston, MA, using a semi-structured interview guide. Nurses were recruited via email notifications and subsequent snowball sampling. Interviews were recorded, transcribed and analyzed using a grounded theory approach.


Data from in-depth interviews with 22 nurses were grouped into six themes: (1) stigma, (2) assessing & treating pain, (3) feelings of burn out, (4) communication between providers, (5) safety & security, and (6) opportunities for change. These themes were organized within four ecological levels of the Socio-Ecological Model: I) societal context, II) hospital environment, III) interpersonal interactions, and IV) individual factors. Nurses were cognizant of the struggles that patients who have opioid use disorder confront during hospitalization such as pain, withdrawal and stigma, and elaborated on how these challenges translate to professional and emotional strain among nurses. Nurses offered recommendations by which the hospital could streamline care for this population, including expanded role support for nurses and more structured policies regarding care for patients who present with a comorbid opioid use disorder.


Our results highlight the need for the development of programs targeting both organizational culture and the inpatient nurse quality of life to ultimately enhance quality of care for patients who present with opioid use disorder.

Klíčová slova:

Addiction – Allied health care professionals – Inpatients – Nurses – Opioids – Pain management – Patients – Psychological stress


1. Substance Abuse and Mental Health Services Administration (SAMHSA): Center for Behavioral Health Statistics and Quality. National Survey on Drug Use and Health: Detailed tables. Rockville, MD; 2017 Sep.

2. Barocas JA, White LF, Wang J, et al. Estimated prevalence of opioid use disorder in Massachusetts, 2011–2015: A capture-recapture analysis. Am J Public Health. 2018;108(12):1675–81. doi: 10.2105/AJPH.2018.304673 30359112

3. Center for Substance Abuse Treatment. Managing chronic pain in adults with or in recovery from Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2012. (Treatment Improvement Protocol (TIP) Series, No. 54.) Exhibit 2–6, DSM-IV-TR Criteria for Substance Abuse and Substance Dependence. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92053/table/ch2.t5/

4. Commonwealth of Massachusetts: Health Policy Commission. Opioid use disorder in Massachusetts: An analysis of its impact on the health care system, availability of pharmacologic treatment, and recommendations for payment and care delivery reform. Boston, MA; 2016 Sep.

5. Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. Opioid-related inpatient stays and emergency department visits by state, 2009–2014. HCUP Statistical Brief #219. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2016 Dec. 28682575

6. Tedesco D, Asch SM, Curtin C, et al. Opioid abuse and poisoning: Trends in inpatient and emergency department discharges. Health Aff. 2017;36(10):1748–53.

7. Bearnot B, Mitton JA, Hayden M, Park ER. Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study. J Subst Abuse Treat. 2019;102:16–22. doi: 10.1016/j.jsat.2019.04.008 31202284

8. Englander H, Collins D, Peterson Perry S, Rabinowitz M, Phoutrides E, Nicolaidis C. “We’ve learned it’s a medical illness, not a moral choice”: Qualitative study of the effects of a multicomponent addiction intervention on hospital providers’ attitudes and experiences. J Hosp Med. 2018;13(11):752–8. doi: 10.12788/jhm.2993 29694454

9. Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;57:104–10. doi: 10.1016/j.drugpo.2018.04.004 29715589

10. Biancarelli DL, Biello KB, Childs E, et al. Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug Alc Dependence. 2019;198:80–6.

11. Brener L, Von Hippel W, Von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug and Alc Review. 2010;29:491–7.

12. van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Depend. 2013;131(1–2):23–35. doi: 10.1016/j.drugalcdep.2013.02.018 23490450

13. McNeil R, Small W, Wood E, Kerr T. Hospitals as a risk environment: An ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med. 2015;105:59–66.

14. Sleeper JA, Bochain SS. Stigmatization by nurses as perceived by substance abuse patients: A phenomenological study. J Nursing Edu Pract. 2013;3(7):92–8.

15. Brener L, Von Hippel W, Kippax S, Preacher KJ. The role of physician and nurse attitudes in the health care of injecting drug users. Subst Use Misuse. 2010;45(7–8):1007–18. doi: 10.3109/10826081003659543 20441447

16. Compton P, Blacher S. Nursing education in the midst of the opioid crisis. Pain Manag Nurs. 2019; doi: 10.1016/j.pmn.2019.06.006 31358464

17. Lewis LF, Jarvis L. Undergraduate nursing students' experiences and attitudes towards working with patients with opioid use disorder in the clinical setting: A qualitative content analysis. Nursing Educ Today. 2019;73:17–22.

18. Glanz K, Rimer BK. Theory at a glance: a guide for health promotion practice. Washington D.C: National Cancer Institute, National Institutes of Health, Public Health Service, U.S. Dept of Health and Human Services; 1997.

19. Mills J, Birks M, Hoare K. Grounded Theory. In: Mills J, Birks M, editors. Qualitative Methodology: A Practical Guide. New York City: SAGE; 2014. p. 107–22.

20. Bronfenbrenner U. Toward an experimental ecology of human development. Am Psych. 1977;32(7):513–31.

21. Lounsbury DW, Mitchell SG. Introduction to special issue on Social Ecological Approaches to Community Health Research and Action. Am J Community Psychol. 2009;44:213–20. doi: 10.1007/s10464-009-9266-4 19777338

22. Kelly LA, Lefton C, Fischer SA. Nurse leader burnout, satisfaction and work-life balance. J Nurs Adm. 2019;49(9):404–10. doi: 10.1097/NNA.0000000000000784 31425307

23. Hoge MA, Stuart GW, Morris J, Flaherty MT, Paris M Jr, Goplerud E. Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis. Health Aff. 2013;32(11):2005–12.

24. Skinner N, Roche AM, Freeman T, Addy D. Responding to alcohol and other drug issues: The effect of role adequacy and role legitimacy on motivation and satisfaction. Drugs: Educ Prev Policy. 2005;12(6):449–63.

25. Monks R, Topping A, Newell R. The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: a grounded theory study. J Adv Nursing. 2013;69(4):935–46.

26. Mooney M, O’Brien F. Developing a plan of care using the Roper, Logan and Tierney model. Brit J Nursing. 2006;15(16):887–92.

27. Wakeman SE, Pham-Kantar G, Donelan K. Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists. Subst Abuse. 2016;37(4):635–41.

28. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Healthcare professionals’ regard towards working with patients with SUDs: Comparison of primary care, general psychiatry and specialist addiction services. Drug Alc Dependence. 2014;134:92–8.

29. Roche A, Nicholas R. Workforce development: An important paradigm shift for the alcohol and other drugs sector. Drugs: Educ Prev Policy. 2017;24(6):443–54.

30. Skinner N, Roche AM, Freeman T, Mckinnon A. Health professionals’ attitudes towards AOD-related work: moving the traditional focus from education and training to organizational culture. Drugs: Educ Prev Policy. 2009;16(3):232–49.

31. Anderson P, Kaner E, Wutzke S, et al. Attitudes and managing alcohol problems in general practice: An interaction analysis based on findings from a WHO collaborative study. Alc Alcoholism. 2004;39(4):351–6.

32. Ford R, Bammer G, Becker N. Improving nurses' therapeutic attitude to patients who use illicit drugs: workplace drug and alcohol education is not enough. Int J Nursing Practice. 2009;15(2):112–8.

33. Skinner N, Roche AM, O’Connor J, Pollard Y, Todd C (Flinders University, Adelaide, Australia). Workforce Development TIPS (Theory Into Practice Strategies): A Resource Kit for the Alcohol and Other Drugs Field. Overview Booklet and CD-Rom. National Centre for Education and Training on Addiction (NCETA); 2005.

34. Lovi R, Barr J. Stigma reported by nurses related to those experiencing drug and alcohol dependency: A phenomenological Giorgi study. Contemp Nurs. 2009;33(2):166–78.

35. Bride BE, Kintzle S. Secondary traumatic stress, job satisfaction, and occupational commitment in substance abuse counselors. Traumatology. 2011;17(1):22–8.

36. Ewer PL, Teesson M, Sannibale C, Roche A, Mills KL. The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug Alcohol Rev. 2015;34(3):252–8. doi: 10.1111/dar.12204 25355060

37. Wurcel AG, Yu S, Pacheco M, Warner K. Contracts with people who inject drugs following valve surgery: Unrealistic and misguided expectations. J Thorac Cardiovasc Surg. 2017;154(6):2002.

38. Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med. 2016;374(17):1661–9. doi: 10.1056/NEJMra1501998 27119238

39. von Hippel W, Brener L, von Hippel C. Implicit prejudice toward injecting drug users predicts job turnover intentions among drug and alcohol nurses. Psychol Sci. 2008;19(1):7–11. doi: 10.1111/j.1467-9280.2008.02037.x 18181783

40. Ford R. Interpersonal challenges as a constraint on care: The experience of nurses’ care of patients who use illicit drugs. 2011;37(2):241–52.

41. Theisen-Toupal J, Ronan MV, Moore A, Rosenthal ES. Inpatient management of opioid use disorder: A review for hospitalists. J Hosp Med. 2017;12(5):369–74. doi: 10.12788/jhm.2731 28459909

42. Marks LR, Munigala S, Warren DK, Liang SY, Schwarz ES, Durkin MJ. Addiction medicine consultations reduce readmission rates for patients with serious infections from opioid use disorder. Clin Infect Dis. 2018;68(11):1935–7.

43. Englander H, Mahoney S, Brandt K, et al. Tools to support hospital-based addiction care: core components, values, and activities of the Improving Addiction Care Team. J Addiction Med 2019;13(2): 85–9.

44. Englander H, Weimer M, Solotaroff R, et al. Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder. J Hosp Med. 2017; 12(5), 339–42. doi: 10.12788/jhm.2736 28459904

45. American Nurses Association (ANA). Issue Brief–The Opioid Epidemic: The evolving role of the nurse. Silver Spring, MD. 2018 Aug.

46. Bartlett R, Brown L, Shattell M, Wright T, Lewallen L. Harm reduction: Compassionate care of persons with addictions. Medsurg Nurs. 2013;22(6):349–58. 24600929

47. Thakarar K, Weinstein ZM, Walley AY. Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist. Postgrad Med J. 2016;92:356–63. doi: 10.1136/postgradmedj-2015-133720 27004476

48. Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481–5. doi: 10.1016/j.amjmed.2015.09.024 26597670

49. Kishore S, Hayden M, Rich J. Lessons from Scott County -Progress or paralysis on harm reduction? N Engl J Med. 2019;380(21):1988–90. doi: 10.1056/NEJMp1901276 31042821

50. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—Tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063–6. doi: 10.1056/NEJMp1402780 24758595

51. Zhang YY, Han WL, Qin W, et al. Extent of compassion satisfaction, compassion fatigue and burnout in nursing: A meta‐analysis. J Nurs Manag. 2018;26(7):810–9. doi: 10.1111/jonm.12589 30129106

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2019 Číslo 10