Ford, Bammer, and Becker. (2008) Australia 1605 Registered Nurses (1) To explore the determinants of general nurses therapeutic attitudes to patients who use illicit drugs Quantitative Design Cross Sectional Survey Self –Report questionnaire Postal Questionnaire Survey Questionnaire consisted of the following measures: Therapeutic Attitude measured using a modified 27-item version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ; Cartwright, 1980) Characteristics Attitudes to illicit drugs – measured using the Disapproval of Drug Use Scale (DDU; Caplehorn et al. 1996). Practice Factors: Basic Role Requirements Professional Practice Factors: Workplace Factors Nurses struggled to care for illicit drug Nurses reported low levels of education adequacy (25%), motivation to care (30%) and satisfaction (15%) in role A negative attitude towards illicit drugs was found to be significantly associated with therapeutic attitudes 44% of participants said they did not have role support Increased role support was suggested to increase therapeutic attitude. Self-Report – desirability bias? Sectional Study – only provides a snapshot at a specific time, hence may not be representative Postal Questionnaire bias and low response Attitudes are measured towards “drug related problems” – type of drug is not specified, cannot be sure which drug participants are calling to mind when they respond 95% Ford (2011) Australia 311 Registered Nurses from the above sample of 1605 registered nurses (1) To explore the challenges nurses face when caring for patients who use illicit drugs This study is the second part of the larger study described above Qualitative Data of this paper is on interpreting the responses to one of the questions the initial survey Question asked participants to describe any factors that negatively impacted their ability to care for patients using illicit substances Findings identified violence, manipulation and irresponsibility as an impediment to care Nurses reported: Feelings of frustration with working with patients illicit drugs Feeling concerned about their safety -believing illicit drug users can be unpredictable and are often aggressive Patients can be intimidating and demanding Patients are seen as manipulative, particularly with regards to medication Secondary data analysis – so findings may not be directly interpretable Low response rate – 311/1605 answered this question – again not very generalisable Self-selection bias in of nurses choosing to answer this question 80%
Krawczyk, and Bastos. (2015) Brazil 38 adult crack cocaine users from Rio de Janeiro and Sãn Paulo To explore crack cocaine users perspectives regarding how social and contextual factors influence use of health and social services Qualitative Design Convenience Sample 1:1 in-depth semi-structured interviews and Focus groups Interviews and Focus groups covered the following topics: patterns of use of crack cocaine and other drugs, childhood and family history of use, motivations around drug use, violence, social norms, perception of stigma and discrimination, availability and accessibility of health and social services, Content Analysis In Rio de Janeiro, most participants reported frustration at health services. Many had experienced discrimination from staff, whereby they described being treated rudely or with disgust Conversely, in Sãn Paulo, most participants reported having positive experiences with health services – describing being treated with care and attention Participants’ experiences of stigma and discrimination clearly vary from city to city and this may be influenced by variations in drug policies and overall attitudes to drug use across the different cities. Qualitative Study – limited in terms of its genralisability Self-Report data may lead to bias and socially desirable responses 70% Lincoln, Berryman, and Linn. (1973) USA 52 Staff from Drug treatment services 36 Drug Users 24 First Year Graduate Social Workers To explore differences of staff, drug users and students’ attitudes towards drug users. Quantitative Design Cross Sectional design Osgood’s Semantic Differential (Osgood, Suci, Tannenbaum, 1967) was used to measure attitudes towards drug users Participants were presented with the following concepts: Police, amphetamine user, marijuana user, heroin user, LSD user, and pusher 10 adjective pairs were selected across six concepts and were summed to give an overall attitude score for each concept Staff, social work students and drug users’ attitudes were found to be significantly different across all concepts The most positive attitude of staff was towards the police The most positive attitude of both the students and the drug users was towards the marijuana user The most negative attitude of both the staff and students was towards the pusher The drug users most negative attitude was tied between the pusher and heroin users Students responses were less positive than the staffs – with the exception on marijuana and heroin use Despite efforts to make responses anonymous, data may lead to bias and socially desirable responses No details about the concepts – Drug users in treatment – hence not generalizable to drug users 85% Report Filho,
Soverow, Rosenberg, and Ferneau. (1972) USA 120 heroin addicts in treatment – 60 were questioned about drug use and addiction, whilst the latter group were asked about alcohol and alcoholism 37 members of staff To compare heroin addicts’ attitudes towards themselves and their addiction with those of the staff working with them Quantitative design Cross Sectional questionnaire Self report Participants randomly approached and asked to participate in the study Questionnaire based study consisting of 40 statements assessed on a 7 point Likert Scale When comparing the responses from the participants who use heroin to the staff responses: Staff felt that emotional difficulties were more important in causing addiction Staff were more optimistic about recovery Staff did not feel that the use of large amounts of drugs was necessary to cause addiction Staff were more willing to conceptualise addiction as an illness Staff were less willing to consider addiction as harmless indulgence Client Participants had all been involved in methadone maintenance treatment for some time – may not be representative of heroin users Self- selected sample – 20% approached, refused to participate Self-report data – responses to questionnaires may be subject to social desirability bias 56%
in Profession 5 or less 15 (24.2) N/A 6 – 10 years 12 (19.4) N/A 11-20 years 21 (33.9) N/A 21 – 30 7 (11.3) N/A More than 30 7 (11.3) N/A under care of /working in Substance Use Teams 5 years or less 19 (30.6) 43 (56.6) 6 – 10 12 (19.4) 12 (15.8) 11-20 years 24 (38.7) 17 (22.4) 21 – 30 7 (11.3) 3 (3.9) More than 30 0 1 (1.3) Have you or your friends/family ever used illicit substances Yes 47 (75.8) 76 (100) No 15 (24.2) 0 Drug Use in Past Six Months / Ever used – for professionals Cannabis: - Yes - No 44 (71) 18 (29) 18 (23.7) 58 (76.3) Cocaine: - Yes - No 38 (61.3) 24 (38.7) 33 (43.4) 43 (56.6) Heroin: - Yes - No 15 (24.2) 47 (75.8) 76 (100) 0 Amphetamines: - Yes - No 23 (37.1) 39 (62.9) 6 (7.9) 70 (92.1) Ecstasy: - Yes - No 25 (40.3) 37 (59.7) 6 (7.9) 70 (92.1) Ketamine: - Yes - No 11 (17.7) 51 (82.3) 3 (3.9) 73 (96.1) LSD: - Yes - No 16 (25.8) 46 (74.2) 2 (2.6) 74 (97.4) PCP: - Yes - No 1 (1.6) 61 (98.4) 0 76 (100) Legal Highs: - Yes - No 10 (16.1) 52 (83.9) 2 (2.6) 74 (97.4) Other: - Yes - No 6 (9.7) 56 (90.3) 22 (28.9) 54 (71.1)
Table 4: Common and Distinct Qualities between Clients and Healthcare Professionals Distinct – Clients Common Distinct – Professionals Positive Qualities Understanding Fair/ equal treatment Professionals being an Ex-user Being honest Polite Good Time Keeping Professionals being positive Kind/ Friendly staff Service being helpful Flexibility Providing information/ advice Treated as an individual/ person centred Collaborative Working Listening Respect Being Being empathetic Being open Adhering to boundaries Professionals being positive Knowledge Professional is approachable/ welcoming Client motivated to change Negative Qualities Being condescending/ patronizing Lack of trust Professionals lack of belief re change Lack of manners Lack of understanding Negative Body Language Stigmatising/ Discriminatory attitudes Being told what to do Professionals being negative Making Assumptions Lack of respect Service/ Professional unhelpful Not Caring Poor environment for meetings Poor Time Keeping Not Listening Being judged Aggressive/ inappropriate behaviour Lack of knowledge Poor communication Professional disinterested
Table 5: Dependent Variable Clients Healthcare Professionals Main Effect: Participant Group Main Effect: Control Condition Interaction Effect: Participant Group and Control Condition M (SD) M (SD) F (df) P () F (df) P () F (df) P () Positive Stereotypesa 2.76 (.68) 3.42 (.47) 39.81 (1, 131) <.001 (.23) 1.41 (1, 131) .24 (.01) 2.52 (1, 131) .12 (.02) Rehabilitation Expectationsa 2.96 (.94) 3.32 (.79) 5.62 (1, 131) .02 (.04) 0.04 (1, 131) .85 (<.001) 6.42 (1, 131) .01 (.05) Social Distanceb 3.88 (.70) 3.07 (.65) 45.90 (1, 130) <.001 (.26) .55 (1, 130) .46 (<.01) 0.14 (1, 130) .71 (<.01) Attribution Beliefsa: Attributions of Responsibility 4.20 (.82) 3.85 (.74) 6.65 (1, 131) .01 (.05) .52 (1, 131) .47 <.01 .02 (1, 131) .89 <.001 Attributions of Control 2.07 (1.02) 2.58 (.91) 8.88 (1, 131) <.01 (.06) .00 (1, 131) .98 (<.001) 4.22 (1, 131) .04 (.03) Attributions of successful treatment 3.92 (.88) 4.36 (.74) 11.13 (1, 131) .001 (.08) 16.22 (1, 131) <.001 (.11) .27 (1, 131) .60 <.01 Attributions about Addiction being a disease 3.88 (.97) 2.83 (1.15) 33.83 (1, 131) <.001 (.21) .82 (1, 131) .37 (<.01) 1.11 (1, 131) .30 <.01
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Earnshaw, V. A., & Quinn, D. M. (2012). The impact of stigma in healthcare on people living with chronic illnesses. Journal of Health Psychology, 17, 157-168. Earnshaw, V., Smith, L., & Copenhaver, M. (2013). Drug addiction stigma in the context of methadone maintenance therapy: An investigation into understudied sources of stigma. International Journal of Mental Health and Addiction, 11, 110-122. Edwards, D., & Potter, J. (1993). Language and causation: A discursive action model of description and attribution. Psychological Review, 100, 23-41. European Monitoring Centre for Drugs and Drug Addiction. (2016). European Drug Report 2016: Trends and Developments. Retrieved December 18, 2016, from Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* 3: A flexible statistical power analysis program for the social, behavioural, and biomedical sciences. Behaviour Research Methods, 39, 175-191. Fehr, B. (1988). Prototype analysis of the concepts of love and commitment. Journal of Personality and Social Psychology, 55, 557-579. Fine, M., & Asch, A. (1988). Disability beyond stigma: Social interaction, discrimination, and activism. Journal of Social Issues, 44, 3-21. Gilchrist, G., Moskalewicz, J., Slezakova, S., Okruhlica, L., Torrens, M., Vajd, R., & Baldacchino, A. (2011). Staff regard towards working with substance users: a European study. Addiction, 106, 1114-1125. Goffman, E. (1963). Stigma. Notes on the Management of Spoiled Identity. New York: Simon and Shuster. Henderson, C., Corker, E., Lewis-Holmes, E., Hamilton, S., Flach, C., Rose, D., ... & Thornicroft, G. (2012). England's time to change antistigma campaign: one-year
Service/Treatment options and choices are made to the client 6.0 (8) 0.0 13.1 (8) Expected cell frequencies below 5 Professionals assertive and direct/challenge 6.0 (8) 5.5 (4) 6.6(4) Expected cell frequencies below 5 Professional not abusing power 5.2 (7) 9.6 (7) 0.0 Expected cell frequencies below 5 Client made to feel comfortable 5.2 (8) 8.2(6) 3.3 (2) Expected cell frequencies below 5 Seeing same professional each week 5.2 (7) 6.8 (5) 3.3 (2) Expected cell frequencies below 5 Fast response/action 4.5 (6) 8.2(6) 0.0 Expected cell frequencies below 5 Experienced professionals 4.5 (6) 2.7 (2) 6.6 (4) Expected cell frequencies below 5 Positive Body Language 4.5 (8) 1.4 (3) 8.2 (5) Expected cell frequencies below 5 Clear expectations and goals 4.5 (6) 0 9.8 (6) Expected cell frequencies below 5 Holistic care 3.7 (5) 5.5 (4) 1.6 (1) Expected cell frequencies below 5 Acceptance 3.7 (5) 4.1 (3) 3.3 (2) Expected cell frequencies below 5 Asking questions and showing an interest, allowing me to talk about anything 3.7 (5) 1.4 (1) 6.6 (4) Expected cell frequencies below 5 Professionals supportive 3.0 (4) 4.1 (3) 1.6 (1) Expected cell frequencies below 5 Staff engaging with what is going on for me at the time - not pressuring to do what they want 3.0 (4) 1.4 (1) 4.9 (3) Expected cell frequencies below 5
Client led 3.0 (4) 0 6.6 (4) Expected cell frequencies below 5 Professionals being supported to support clients 3.0 (4) 0 6.6 (4) Expected cell frequencies below 5 Client able to experiences with staff 2.2 (3) 4.1 (3) 0 Expected cell frequencies below 5 Good relationship with key worker 2.2 (3) 1.4 (1) 3.3 (2) Expected cell frequencies 5 Safe and appropriate environment 2.2 (3) 0.0 4.9 (3) Expected cell frequencies below 5 Allow time for rapport to build 2.2 (3) 0.0 4.9 (3) Expected cell frequencies below 5 Staff sticking to promises 2.2 (3) 0 4.9 (3) Expected cell frequencies below 5 Acknowledging difficulties for client 2.2 (3) 0 4.9 (3) Expected cell frequencies below 5 Checking on client 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Professionals not reading like a text book 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 1:1 time 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Being treated like an adult - staff not condescending 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies 5 Able to collect meds/script 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Being genuine 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies below 5
Client taken seriously 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies 5 Free choice to attend 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies below 5 Insight 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies below 5 Creating space for client to talk openly 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Give client hopes and aims 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Provide realistic solutions 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Tolerance 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Remain professional 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Showing compassion 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Carefully executed humour 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Not making assumptions 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Exploring reasons for relapse 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Reassuring each other 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Not schizophrenic 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5
Supporting client accessing leisure activities to occupy time and reduce risk of use 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals should have training to help them understand 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Someone who admits they do not know what it feels like but listens to your story, not just the heroin story 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Being offered counselling/CBT - helping you to understand how the past may have contributed to the addiction 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Not made to feel that you are wasting time 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Being treated as a human being 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Staff understanding that sometimes it's not drugs causing the problems 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Able to have a general chat - not all about substance use 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals being there if you want them 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Being made to feel that they are actually in the room with client 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Not made to feel like I have a "problem" 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Someone who what you are going through- not necessarily taken drugs but has the information 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Impartiality from the team 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5
Professional not labelling 0.7 (1) 0 1.6 (1) Expected cell frequencies 5 Appropriate Behaviour 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Involving family members in assessment and treatment 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Making that connection by meeting the client on the same level 0.7 (1) 0 1.6 (1) Expected cell frequencies 5 A relaxed manner 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Not punitive 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Practical 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Not focussing on all the failed attempts at getting clean 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 of psychosocial to help identify any triggers or maintaining factors for addiction 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Not showing negative responses to disclosure of inappropriate behaviour 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 For the client to feel valued 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Service user to not be heavily under the influence for meeting 0.7 (1) 0 1.6 (1) Expected cell frequencies 5 Non Confrontational 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 to able to give feedback, positive but also anything that can be improved on 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5
Just filling in 2.2 (3) 0.0 4.9 (3) Expected cell frequencies below 5 Professionals unreliable 2.2 (3) 0.0 4.9 (3) Expected cell frequencies below 5 Not involving family 1.5 (2) 1.4 (1) 1.6 (1) Expected cell frequencies below 5 Ignoring client 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Not receiving appointment reminders as requested 1.5 (2) 2.7 (2) 0 Expected cell frequencies 5 Not being offered groups /support above prescriptions 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Staff not organised 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Professionals too busy to see you 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Professionals have too high expectations 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Punished for being honest / unclear urine test 1.5 (2) 2.7 (2) 0 Expected cell frequencies 5 Professionals laughing at you / taking the piss out of you 1.5 (2) 2.7 (2) 0 Expected cell frequencies below 5 Professional being over friendly 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Professionals being opposite of positive answers 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Professionals not showing compassion 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5
Professionals critical 1.5 (2) 0 3.3 (2) Expected cell frequencies 5 Not ready for treatment - forced to attend 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Not offering options 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Being too clinical / over professional 1.5 (2) 0 3.3 (2) Expected cell frequencies below 5 Bad atmosphere 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Not the right person 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 No incentive 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals not passionate about their job 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals not following code of conduct 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Not having a good relationship with key worker 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Healthcare involving police 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5 Inaccurate record keeping 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals trying to "mug off client" - just take this 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professional not able to advise on changes in medication 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5
Treated differently to others 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals not thinking about the consequences of taking off medication 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 No introduction 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Negative conversations - told same thing over and over 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Continued requests for urine samples even after admitting you have failed 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Being put on supervised methadone 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Problems brushed under the carpet 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Pressure of yielding good results to show progress towards abstinence 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professional too jokey 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Expect same from service that they would expect 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Being expected to attend groups 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Double standards 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Unfriendly 0.7 (1) 1.4 (1) 0 Expected cell frequencies below 5 Professionals words client does not understand 0.7 (1) 1.4 (1) 0 Expected cell frequencies 5
Unrealistic caseload 0.7 (1) 0 1.6 (1) Expected cell frequencies 5 Looking down on client 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Bringing own core beliefs in to clients world 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Different agendas 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 No goals/reviews 0.7 (1) 0 1.6 (1) Expected cell frequencies 5 Collusion from professional 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5 Inaccurate advice 0.7 (1) 0 1.6 (1) Expected cell frequencies below 5