The latest estimates from the World Health Organization (WHO) are that nearly 35 million of the world's population are affected by harmful substance use and dependence, and harmful use of alcohol accounts for nearly 5.3% of deaths worldwide (WHO, 2022a; 2024). Despite the evident burden of substance misuse on the world's population, healthcare workers (HCWs) may not associate this with hospital admissions. This may be because of insufficient research into this area, despite some studies highlighting this occurrence (Barnett et al, 2021). A recent study from the USA indicated that between 33% and 41% of hospitalised individuals have used illicit substances during their admission (Eaton et al, 2020). Similarly, a Canadian study noted that of the 1028 participants who were admitted to hospital, 43.9% reported using substances during their hospital stay (Grewal et al, 2015). From an Irish perspective, recent data shows that figures for drug-related admissions are increasing, with 5457 individuals being admitted to hospital in 2020 (of whom 55 died in hospital, leaving 5402 non-fatal overdose admissions) (Millar, 2022). These three studies highlight the inevitability of nurses encountering individuals who use substances in a general hospital setting.
These figures highlight the need for HCWs in the general hospital setting to reappraise their attitude towards addiction, as these hospital admissions can be impeded by stigma and insufficient knowledge on the HCW's part (Barnett et al, 2021). For nurses employed in acute general hospitals this is particularly relevant as they may encounter patients admitted for a variety of reasons with concurrent substance misuse (Rassool, 2011). Alongside this, nurses make up nearly 50% of the global healthcare workforce (WHO, 2022b), highlighting the integral role of nurses' understanding of addiction and recovery.
The concept of substance use and addiction has been present in writings as far back as Ancient Greece. Aristotle first wrote about ‘akrasia’ or ‘weakness of the will’ (Glackin, 2020), leading to the understanding that addiction is a moral failing, which is the foundation of the moral model of addiction (Barnett et al, 2018). Meanwhile, Pickard (2017) attempted to shift focus away from stigma and moral failings of the individual towards a framework that allows intervention without blame. These are just two examples of many, which result in different understandings of addiction, leaving individuals who provide care to those with substance use issues with an unclear strategy of intervention and acceptable terminology use.
This has led to models and philosophies being developed to give clarity to a concept that has threads woven through many issues including physical, social, neurological, legal, pharmacological, and moral concerns (West and Brown, 2013). Although the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2013) and the International Classification of Diseases (ICD) (WHO, 2019) attempted to standardise the language of addiction and recovery, these classifications are deep rooted in the works of Edwards and Gross (1976), who were the first to articulate addiction as a clinical disease, thereby introducing the bidimensional model of addiction (Saunders et al, 2019). In turn, these models, perspectives, and terminologies, while all working to comprehend the complexities of addiction, have resulted in confusion and misconception. Significantly, the moral model of addiction, which has sometimes negative connotations, may invoke stigma towards the individual using substances, thereby adversely influencing HCWs' language and care (Frank and Nagel, 2017).
There is no universal definition of ‘recovery’, and it is often used interchangeably with words such as ‘remission’ or ‘abstinence’ (Laudet, 2007). The literature often refers to recovery as the result of treating an addiction (Sterling et al, 2008; el-Guebaly, 2012). Despite this, it has been determined that recovery is not limited to abstinence (Neale et al, 2014). The American Society of Addiction Medicine definition includes the concept of recovery as being the state of a person's health and wellbeing while being abstinent from illicit and licit substances (Galanter, 2007; el-Guebaly, 2012). This was challenged by White and Kurtz (2005) who suggested that recovery is a process encompassing not just the person using substances, but also their family and the wider community, and this enables the person to overcome their problems to lead a life that is healthy and has purpose while managing their vulnerabilities on an ongoing basis.
Although there are several models, philosophies and opinions surrounding the concepts of addiction and recovery, their common thread is language. Language can not only result in attitudes bound by stigma, but it can also, in turn, affect social, public and health policies that address these issues (Wakeman, 2013). The terminology used about these concepts is important to avoid stigma and ensure individuals receive appropriate care (Kelly et al, 2016). It is widely known that nurses' use of language regarding patients frames the care they provide, therefore, nurses should be both conscious of and informed in the language they use (Valdez, 2021). To address this, there have been numerous calls to change certain terms surrounding addiction and recovery (Wakeman, 2013; Kelly et al, 2015; 2016; Zgierska et al, 2021). Suggestions have included moving language away from what the individual is seeking treatment for, allowing nurses to see the patient as an individual, not just the symptoms they are treating (National Institute on Drug Abuse, 2021). Alongside this, recent development of a nurse-led model of care is paving the way for this change. Although the previous models mentioned are medical focused, the Healthy Addiction Treatment (HAT) model is client-need driven, nurse-led and addresses both the mental and physical health of the individuals in an Irish context (Comiskey et al, 2019).
Due to this new model development, the study here aimed to explore Irish nurses' current perception and knowledge of addiction and recovery in patients presenting to acute general hospitals.
Methods
Design
This study involved interviews using a descriptive, qualitative design to allow for flexibility and interpretation of healthcare and nursing-related experiences (Kim et al, 2017).
Data collection
The study involved semi-structured interviews of nurses working in the acute general hospital setting. As part of the interview schedule, participants were asked about their understanding of addiction and recovery and their clinical and academic experience of this topic. Qualitative, in-depth interviews were conducted via video call (Zoom) due to the restrictions of the COVID-19 pandemic and delivered via set questions and prompts. The decision to use qualitative methods was made as this determines the experience of participants and identifies themes (Gerrish and Lacey, 2010), which allows for the aim of determining nurses' understanding of addiction and recovery to be achieved.
Sampling and recruitment
To achieve the study aims, and to ensure the inclusion criteria of the study were met, purposive sampling was used to recruit participants for qualitative interviews. Only staff working in the chosen hospital, a large inner-city hospital in Dublin, Ireland, were approached to take part in the study. Included were nurses who provided care to, or had any contact with, patients who had a history of substance use. Excluded were participants under 18 years old. Ethical approval was sought from and given by both Trinity College Dublin and the chosen university hospital.
Data analysis
The interviews of all 11 nurses were recorded and transcribed by the primary researcher verbatim. To analyse the data thematic analysis was utilised to allow for identifying, analysing and synthesising themes within the obtained data (Braun and Clarke, 2006). Cross-checking of themes was done to ensure appropriate thematic analysis was undertaken.
Findings
The findings presented are the participants' understanding of the concepts of addiction and recovery in relation to substance use. Of the 11 participants interviewed in this study, 9 were female and 2 were male. There was a wide variety in experience level of the nurses, ranging from 18 months qualified to 30 years, alongside diversity in the settings these nurses worked in. Several participants (n=5) were clinical nurse specialists (CNSs) working in areas such as HIV treatment, tissue viability, and epilepsy. Four nurses were working in the intensive care unit (ICU) and the emergency department (ED) at the time of the interviews. The remaining participants (n=2) were working in a ward setting. Although none of the participants had any formal qualifications relating to addiction, they all had close contact and experience of nursing patients with addiction-related issues in the hospital.
The first theme that emerged from the interviews was nurses' understanding of addiction. This included topics that, surprisingly, were not related to their patients' immediate physical care but rather their perception of trauma, psychological wellbeing, and physical needs. The second theme was focused on recovery with sub-themes of the requirement for patient-centred services and the impact of the individual's environment.
Understanding of addiction
Several explanations and comprehensions of addiction were expressed by the nurses, and fell into three sub-themes: trauma, psychological wellbeing, and physical need of the patients.
Trauma
Some of the nurses working in acute areas, such as ICU and ED, associated addiction with physical symptoms. The nurses who had more than 10 years' experience or worked in CNS roles spoke about trauma when articulating their understanding of addiction and linked it to psychological factors. One participant related addiction back to her experience of caring for those individuals in a surgical-ward setting, and the physical injuries and trauma sustained because of substance use:
‘I was max fax (maxillo-facial) … so you would see the fractured mandibles from the domestic violence part of the addiction as well as the alcohol from a point of view of fighting after going on a binge … so the trauma aspects yes you can definitely see that.’
Participant 1
The effects of substance use and the trauma it inflicts on the individual was highlighted by another participant who considered not only the effects addiction has on the individual using the substance, but also the effects on those surrounding them:
‘It's a behavioural issue but also more than that … it's basically a life-encompassing habit that makes life miserable from those dealing with it and those around them.’
Participant 5
Attempts to numb the physical and psychological trauma the individual feels was a significant understanding of one participant:
‘You know whether its physical or psychologically it's addictive it's really just about numbing pain and the pain goes away and you just want that sensation again and again.’
Participant 2
Psychological wellbeing
One participant commented on the desperation of individuals using substances and how this can affect their wellbeing, although the language used by this participant may hold negative connotations:
‘I guess something that someone is dependent on to maybe even get them through their day that they can't go a day without and that … a lot of people would kind of sell their souls almost to get whatever it is they're addicted to.’
Participant 11
Emotional and psychological wellbeing, and its association with addiction, was highlighted by several participants:
‘I would understand it as a crutch whether it be for psychological … emotional.’
Participant 4
Only one participant spoke about addiction as a mental health condition and did not consider using substances to be physically mediated:
‘I would have a lot of experience with working with people with addictions and my understanding of it would be … as a mental health condition.’
Participant 9
Physical need
Physical need was a significant association of addiction with several participants, with one highlighting that individuals may continue substance use by being introduced by their peers, but subsequently lose control due to cravings associated with physical requirements:
‘Who would have been introduced to it at whatever point in their life by friends whoever and liked it liked the feeling and just became addicted and that is something beyond their control because it becomes a physical need but they're not using it as an emotional, an emotional getaway or support.’
Participant 4
Another participant recalled their experience with these patients on a ward:
‘They feel like they can't live without said substance.’
Participant 6
Several participants linked addiction with both physical and psychological symptoms:
‘A need to take certain substance … it could be physical it could be mental something that people feel they just can't live without.’
Participant 7
Understanding of recovery
Recovery was associated with the individual who uses substances themselves recognising they had an issue with addiction and reaching out for help. Alongside this, the individual's environment was a significant theme that participants highlighted in their understanding of recovery in relation to substance use.
Patient-centred services
One participant considered that the first point for recovery-aimed intervention could be when the individual recognises their addiction and asks for help:
‘It's not linear … it can be very much so up and down … people can relapse … maybe the first step would just be recognising they have an issue and reaching out for assistance.’
Participant 11
Several of the participants linked recovery directly with client services, with one highlighting that recovery is a way to overcome addiction in an integrated and patient-centred way, stating:
‘A very holistic approach to looking at the causes for addiction in a case-by-case basis and setting out a programme for an individual … working out individual goals that they could achieve throughout their recovery and hopefully overcoming their addiction as quickly as they can.’
Participant 9
Impact of triggers and environments
Participants associated recovery with service engagement and willingness to change, but also highlighted the importance of finding the causative factors of using substances in the first instance and strategies to overcome past traumas and triggers:
‘There's lots of aspects as why people are doing really well in recovery you know … they've got away from a particular abusive relationship … and they're doing really well on whatever programme they're on.’
Participant 1
One participant described addiction recovery as determining initial causes and ongoing triggers for the individual and highlighted the necessity of that individual's willingness to engage with services and supports:
‘I think it's about identifying what the, that underlying cause is and all the factors that kind of trigger someone so if that's their environment and trying to remove those or heal those in a sustained way in in a way that they can continue that healing … timing is really important in terms of recovery … it needs to be something someone's ready to do.’
Participant 2
Discussion
The primary aim of this research was to determine nurses' understanding of addiction and recovery surrounding substance use. Although there are certain similarities in the participants' responses on their understanding of addiction, there are also stark contrasts. The nurses had various understandings of the concept of addiction and some of the language used to articulate their understanding may have a negative impact on patient care. The lack of knowledge surrounding what is addiction may be received negatively (Monks et al, 2012). Notably, participants were divided when deciding whether addiction is physical or psychological and some participants linked the two. In contrast to these findings, a study undertaken involving mental health nurses observed that the nurses in that study reported providing care beyond physical symptoms (Johansson and Wiklund-Gustin, 2015).
Although some of the participants linked recovery with abstinence, many associated it with client services. Although the abstinence-based understanding of recovery feeds into the medical model and moral model of addiction, the benefits of the harm-reduction approach have been documented widely in the literature (Hawk et al, 2017). Moving away from the medical models, the HAT model maps relevant features of nursing models to develop a care plan that is focused on the individual client's needs. This model has been implemented in addiction clinics whose sole focus is to treat individuals with substance use issues. Although nurses working in an acute setting may not have this direct focus, they do experience caring for individuals with co-occurring substance use and medical conditions (Comiskey et al, 2021). These findings are beneficial as they indicate the harm-reduction approach to substance use and recovery is at the forefront of the nurse's thinking, and, as noted by Bartlett et al (2013), nurses promoting a harm-reduction approach can have positive impacts on the individual's recovery.
Separate from this, more than half the participants felt recovery was an ongoing, non-linear process, which may take years to accomplish, but taking the first step of seeking help is the most important part. These kinds of responses were also observed by McKay (2021), who noted that recovery needs to be treated with flexibility as an individual's status changes over time and the services they are linked to should be adaptable to this.
Although there has been no direct research undertaken on determining HCWs' understanding of both addiction and recovery, from the above results there is broad comprehension of these related subjects. When addressing the complexities of language surrounding substance use and recovery, simple and clear language is the cornerstone of helping individuals and their healthcare providers to have a holistic comprehension, which will then be reflected in the care they provide (Zgierska et al, 2021).
Limitations
Several limitations to this study must be factored in when interpreting these results. This study was conducted in a single hospital in inner-city Dublin. Although separate locations may have yielded contrasting results, it should also be noted that this hospital has a wide catchment area and has over 800 inpatient beds.
Conclusion
This article focuses on the results of a study involving nurses from an acute general hospital in Ireland and their understanding of addiction and recovery. Despite what some addiction models suggest, addiction is not a choice, but the language nurses use surrounding addiction and recovery is. The findings suggest that nurses working in the acute setting have a diverse and sometimes fragmented understanding of both addiction and recovery, which may affect the care that nurses provide for individuals with addiction who are admitted into an acute hospital. Addiction models have led to language that stigmatises and creates negative connotations for nurses and the wider community. Although more research needs to be done on HCWs' understanding of addiction and recovery, this study involving nurses demonstrates the need for standardising language within nursing education and continuing professional development to enable greater understanding and potentially enhancing patient care and reducing stigma surrounding addiction and recovery.
KEY POINTS
- Nurses working in an acute general hospital encounter individuals with addiction, but their understanding of both addiction and recovery is diverse and sometimes fragmented
- Addiction models have led to language that stigmatises and creates negative connotations for nurses and the wider community and more research needs to be undertaken on healthcare workers' understanding of addiction and recovery
- There is a need to standardise the language of addiction and recovery to deepen understanding and in turn enhance patient care and reduce stigma.
CPD reflective questions
- What is your own understanding of addiction and recovery?
- How might your interpretation of addiction relate to the language that you use to describe it?
- Consider the implications the language used may have on patients and the care they receive, and how it might further stigmatise people