The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: a grounded theory study

ORIGINAL RESEARCH

The dissonant care management of illicit drug users in medical wards,

the views of nurses and patients: a grounded theory study

Rob Monks, Annie Topping & Rob Newell

Accepted for publication 2 June 2012

Correspondence to: R. Monks:

e-mail: [email protected]

Rob Monks BSc PhD RGN

Senior Lecturer

School of Health, University of Central

Lancashire, Preston, UK

Annie Topping BSc PhD RGN

Professor, Director

Centre for Health and Social Care Research,

University of Huddersfield, UK

Rob Newell BSc PhD RGN

Professor, Associate Dean

Nursing Research & Knowledge Transfer,

University of Bradford, UK

MONKS R . , TOPP ING A . & NEWELL R . ( 2 0 1 2 ) 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 00(0), 000–000. doi: 10.1111/j.1365-

2648.2012.06088.x.

AbstractAims. The aim of this study was to explore how registered nurses manage and

deliver care to patients admitted to medical wards and Medical Assessment Units

with complications of drug use and to elicit the experiences and views of those

receiving that care.

Background. Illicit drug use is a major public health problem worldwide. The

physical complications of problem drug use often result in admission to medical

wards. Registered nurses working in these settings have been reported as

possessing negative attitudes towards patients who use illicit drugs and lacking

preparation to provide problem drug use–related care needs.

Design. Grounded theory.

Methods. A grounded theory approach was used to collect and analyse 41 semi-

structured interviews. Data collection and analysis were undertaken in nine

medical wards in the Northwest of England in 2008. A combination of purposive

and theoretical sampling was adopted to recruit registered nurses (n = 29) and

medical ward patients (n = 12) admitted for physical complications of problem

drug use. Data were subjected to constant comparative analysis.

Findings. Two sub-categories emerged: ‘Lack of knowledge to care’ and ‘Distrust

and detachment’ and these formed the core category ‘Dissonant care’. The

combination of lack of educational preparation, negative attitudes and experience

of conflict, aggression, and untrustworthiness appeared to affect negatively the

nurse–patient relationship.

Conclusions. This study illuminated interplay of factors that complicated the

delivery of care. The complexity of caring for patients who are pre-judged

negatively by nurses appears to engender dissonance and disparities in care

delivery. Better education and training, coupled with role support about problem

drug use may reduce conflict, disruption, and violence and facilitate competent

care for these patients.

Keywords: emotional labour, grounded theory, medical wards, nurse–patient

relationship, problem drug use, social judgement, social reciprocity

© 2012 Blackwell Publishing Ltd 1

JAN JOURNAL OF ADVANCED NURSING

Introduction

Despite the many initiatives to curb drug use, the increasing

rates and range of illicit drug consumption remain a global

problem (EMCDDA 2010). The United Nations Office on

Drugs and Crime [UNODC] suggests that ‘at the core of

drug consumption lie ‘problem drug users’ (PDUs), those

who inject drugs and/or are considered dependent, facing

serious social and health consequences as a result’

(UNODC 2010, p. 16). Many national economies are cur-

rently implementing major financial restraint measures and

those seen as undeserving face an even greater chance of

exclusion (Chan et al. 2008, Hill 2010). Services for drug

users are increasingly threatened by budget cuts (EMCDDA

2010). Consequently, more people who use illicit drugs

may access non-specialist acute hospital services with acute,

possibly life-threatening health problems, as more specialist

services become unavailable (UNODC 2010).

In many countries, like the UK, the price of most illicit

drugs is decreasing while availability and purity is increasing

(UK Focal Point 2004, EMCDDA 2005, 2009). Price and

availability have long been associated with increasing levels

of dependency in populations. Femoral abscesses, cellulitis,

deep vein thrombosis (DVT), and overdose are common

physical complications that often bring PDUs, particularly

those injecting, into contact with acute care services leading

to unplanned admission to Accident & Emergency Depart-

ments (A&E), Medical Admission Units (MAUs), and ulti-

mately medical wards. Emergency admissions through A&

E have increased in the UK as have the number of inpatient

beds. MAUs were introduced to improve throughput,

quality of care, and length of stay. They act as observation

centres for short-term admissions and form part of the filter-

ing process where investigations, testing and imaging, and

urgent treatment are instigated. Most have a 24- to 48-hour

length of stay rule (Cooke et al. 2003).

Physical complications tend to present at the most chal-

lenging stage of a drug-using career. They occur when ‘drug

use is no longer controlled or undertaken for recreational

purposes and where drugs have become a more essential

element of an individual’s life’ (Godfrey et al. 2002, p. 9).

In the UK on admission to hospital, these individuals will

be cared for by registered nurses (RNs) who receive little, if

any, educational preparation about illicit drug use and

addiction (Heyes 2002, Harling et al. 2006, Rassool &

Salman 2008). The Nursing and Midwifery Council

(NMC), the UK professional regulatory, and statutory body

responsible for both registration and quality assurance of

programmes preparing nurses for registration list a range of

standards of proficiency for the four branches (adult, child,

learning disabilities, and mental health) pre-registration

nursing education (See Table 1). These relate to broad

issues rather than specific curriculum uniform content

(Rassool 2008) with the consequence that illicit drug use

receives little attention in the adult nurse curricula (Harling

& Turner 2012). Hence, many adult branch RNs in the UK

are likely to be ill prepared to manage and deliver compe-

tent care to PDUs in acute care settings such as medical

wards and medical admission units.

Background

High bed occupancy, rapid patient throughput, high depen-

dence of patients, and increasing use of technology make

MAUs and medical wards challenging work environments.

Patients with diverse conditions and needs, including those

with acute life-threatening illnesses and those requiring

resource intensive care, are admitted to acute medical ward

settings. A consequence of high activity levels is the prioriti-

zation of patients and related needs. PDUs are often judge

as problematic, difficult to manage, demanding, and disrup-

tive and may be seen as less of a priority (McLaughlin et al.

2000, Happell & Taylor 2001, Boyle et al. 2010). Certain

behaviours may be interpreted by RNs as drug-seeking and

lead to symptoms being ignored or interpreted negatively.

For example, reports of severe pain may be interpreted as a

ploy to receive, or increase, dosage of prescribed methadone

or analgesia (Morrison et al. 2000). Methadone dosage and

non-compliance with acceptable patterns of patient behav-

iour may also create tensions. These conflicts may adversely

affect the smooth running of the clinical environment.

Cumulatively, all these factors may contribute to reinforc-

ing any previously held attitudes leading to loss of trust

between patient and caregiver. In effect, the patient is char-

acterized as unable or unwilling to enter into an appropri-

ate reciprocal exchange relationship with their healthcare

provider (Chan et al. 2008).

Table 1 Standards of proficiency.

Competency framework Five essential skills clusters

Professional values Care, compassion, and

communication

Communication and interpersonal

skills

Medicines management

Nursing practice and decision-

making

Organizational aspects of care

Leadership, management, and

team working

Infection prevention and

control

Nutrition and fluid

management

2 © 2012 Blackwell Publishing Ltd

R. Monks et al.

Attitudes to drug users have been studied across a range

of health professionals including RNs (Carroll 1995, 1996,

Chan et al. 2008); general practitioners (Deehan et al.

1997); healthcare staff generally (McLaughlin et al. 2000,

Happell & Taylor 2001, Boyle et al. 2010); and forensic

nurses (Foster & Onyeukwu 2003). Most of these studies

have focused on determining the dimensions and inherent

contradictions in attitudes held rather than examining

the effect attitudes have on the patient experience of

those with a history of problem drug use in acute hospital

contexts.

Given the unplanned nature of admission to acute ser-

vices, the complex interplay between psychological depen-

dence and lifestyle can create a crisis for the individual.

Inpatients do not normally have access to the drugs that

service dependence and PDUs on admission frequently

experience withdrawal symptoms. This leads them to

demand drugs or leave the ward to ‘score’ drugs to service

their dependence. The combination of negative attitudes

and limited education may produce limited drug misuse

competency in RNs and contribute to a poor care experi-

ence for service users (Happell & Taylor 2001, Rassool &

Rawaf 2008). The rationale underlying this study was to

explore the experiences of RNs and patients to understand

the complex interplay between knowledge and attitudes

and its perceived effect on care delivery better.

The study

Aim

This study aimed to explore how RNs manage and deliver

care to patients admitted to medical wards and MAUs with

complications of drug use and to elicit the experiences and

views of those receiving that care.

Design

A grounded theory approach specifically the techniques and

procedures described by Strauss and Corbin (1998) was

used to direct data collection and analysis including con-

stant comparison, theoretical sampling, open, axial, and

selective coding of the data.

Sample and participants

Purposive sampling was used initially to recruit RNs

(n = 29) working in MAUs and Medical Wards in a large

NHS Acute Hospital in North West England in 2008.

Nurses with different biographical details were recruited to

the study (Table 2). As data collection and analysis pro-

gressed, issues that emerged in the interviews that contrib-

uted developing categories directed theoretical sampling.

For example, most nurse participants in this study

expressed negative views of PDUs. During data collection,

several RN participants identified other RNs (n = 3) who

were ‘known’ in the organization for holding more positive

attitudes towards PDUs. These RNs were actively recruited

as a theoretical sample (Strauss & Corbin 1998) to inform

developing tentative assumptions. Convenience sampling

was used to recruit the patient participants who used illicit

drugs (n = 12). RNs working in MAUs and medical wards

initially approached patients admitted with PDU and fol-

lowed a recruitment schedule (Table 3).

Data collection

Semi-structured interviews (minimum 25; maximum

105 minutes) were undertaken. These were audio recorded

Table 2 Biographical details of the nurse participants.

Interviewee no Age Sex

No of years

experience

Type of

nurse

Interview 1 34 Male 9 RN

Interview 2 50 Male 20 RN

Interview 3 30 Female 0·4 RN

Interview 4 50 Female 21 RN


Interview 6 23 Male 0·4 RN









Interview 15 30 Female 6 NA

Interview 16 40 Female 0·6 RN/RMN






Interview 22 30 Male 6 RN/RMN








RN, Registered Nurse; RMN, Registered Mental Nurse.


JAN: ORIGINAL RESEARCH Caring for problem drug users in medical wards

and transcribed prior to analysis. The initial interviews with

RNs began with a request to describe their experiences of

delivering and managing care for patients who were PDUs.

A range of prompts and probes were used in the interview

schedule (Table 4). Patient participants were asked similar

issues about their experience of care delivery in the context

of the medical ward. As conceptual categories began to

emerge from the use of constant comparison, the interview

questions became more focussed. All the nurses interviewed

had been involved in the delivery of direct care to the

patient participants.

Ethical issues

Research Ethics Committee approval was obtained from a

National Health Service (NHS) Local Research Ethics Com-

mittee (LREC) and the University Ethics Committee. Local

governance approval was obtained from the NHS Trust

prior to negotiating access to RNs through unit managers.

Permission to access to the target patient population was

negotiated through the admitting medical consultants and

RNs responsible for their care.

Data analysis

Data analysis was undertaken concurrently with sampling

and data collection. Contemporaneous field notes were kept

to inform analysis and subsequent data collection. Both

transcripts and field notes were analysed manually and sup-

ported with computer-assisted qualitative data analysing

software QSR NVivo 1·3 (Richards 2000). Initially, the

transcripts were examined in detail using memo cards and

different coloured pens for coding. Open coding was used

where sections of data were allocated to tentative categories

that began to form (Strauss & Corbin 1998). As the volume

of data increased, NVivo software was used to manage and

support data handling. This assisted the close detailed anal-

ysis and apportionment of data to the emerging categories.

The properties and dimensions of each category, axial cod-

ing, were explored by comparing how each coded section

of data added to the developing acumen. Data collection

was discontinued when no new properties emerged from

the interviews. As data saturation became evident, selective

coding was undertaken. This process involved integrating

and refining the theory.

Rigour of the study

Several measures were undertaken to enhance the trustwor-

thiness of the data (Denzin & Lincoln 2003). Throughout

data collection and analysis, theoretical and reflexive field

notes were maintained to provide a contemporaneous

account of assumptions, potential biases, and theoretical

explanations. Interview transcripts, where possible, were

returned to the nurse participants to check for accuracy;

this was not possible with the patient participants. No RN

participants chose to amend their account; this was

assumed to indicate accuracy; however, comments were

received about the differences between aural and tran-

scribed accounts. For example, as one RN participant

responded: ‘my comments seem more stark when in a writ-

ten format’. Finally, preliminary findings were presented to

nurse experts in the field and medical ward nurses for feed-

back and as peer review to assess goodness of fit of catego-

rization and overall congruence of the conceptual findings.

Results

Sample characteristics

The RN participants recruited to this study represented a

range of ages (21–58 years), gender (24 females; 5 males)

and experience since qualification (4 months–37 years).

Educational qualifications of the nurses ranged from certifi-

cate level (equivalent to 1 year of undergraduate education)

through Master of Science. All were registered as adult

branch RNs with the Nursing and Midwifery Council

(NMC). All the patient participants reported a history of

poly-drug use including cannabis, amphetamine, ecstasy,

cocaine, crack cocaine, and heroin. All patient participants

reported injecting heroin prior to admission. All were

admitted for acute complications of their drug use and by

definition were ‘problem drug users’ (UNODC 2010,

p. 16).

‘Dissonant care management/delivery’ emerged as the

core category to explain the complexity of the nurse–patient

Table 3 Recruitment process.

Patient admitted to ward declares use of an illicit drug(s)

↓

Inform patient about research study

↓

Give letter of invitation to study + patient information sheet

↓

If patient agrees to participate in study inform researcher (RM,

Tel)

↓

Researcher will come to ward to give further information about

the study, consent the participant, and set up convenient time

for interview


R. Monks et al.

Table

4Interview

schedule.

Interview

schedule

(Nurses)

Prompts

Core

structure

Probes

Iwould

likeyouto

describeformeyourexperience

andviewsofmanagingand

deliveringcaringto

patientwhouse

illicitdrugs

↓

Try

toim

agineatypicalmorning/afternoon/evening/nightduringthat

period….whatsort

ofthingshappened?

Canyougivemeanexample

ofwhathappened

thatmadeyoufeel

thatway?

Gettingback

toyourexperienceswiththepatients…

Are

thereanyparticularexperiencesthatstandoutduringthattime?

Whataboutother

thingspatients

did?

There’snorightorwrongansw

ers,I’djust

liketo

get

youthinking

Identify

values

Identify

hopes

andexpectations

Identify

feelingsofcomfort

withselfandothers

Identify

abilityto

establish

helpingtrustingrelationships

Identify

abilityto

express

positiveandnegativefeelings

Identify

abilityto

solveproblems

Identify

awarenessperceptionsofillnessandgoalsoftreatm

ent

Identify

awarenessofsupportiveprotectiveandcorrectivemental,physical,

societal,andspiritualenvironmentaspects

Whatwas

itlike?

Whathappened

then?

Goon…

Isthereanythingelse?

How

did

thatmakeyou

feel?

How

was

thathelpful?

How

doyoumean?

Tellmemore?

Are

thereanyother

reasons?

Whydoyouthinkthat

happened?

Whatdid

thatmeanto

youatthetime?

Whatwereyouthinking

then?

Finally,whatwould

yousaywerethegoodandbadaspects

aboutcaringfor

patients

whouse

illicitdrugs



interaction and relationships involved in the delivery of care

to PDUs in acute MAUs and medical wards. This core cate-

gory was constructed from two sub-categories: ‘Lack of

knowledge to care’ and ‘Distrust and detachment’.

Lack of knowledge to care

Despite repeated calls in the nursing literature to integrate

drug and addiction content into the curriculum for RNs,

none of the nurse participants in this study had received

any formal pre- or post-registration education to prepare

them to deliver care to patients who were admitted with

complications of illicit drug use. The nurses reported feeling

confident and competent to deal with the physical aspects

of problematic drug use such as DVT or septicaemia. They

felt less confident when managing drug-related patient

needs specifically related to drug use, particularly monitor-

ing and managing withdrawals from heroin or other drugs.

This lack of confidence appeared to be translated into inad-

equate care delivery, something recognized by both the

nurses themselves and their patients. Most nurse partici-

pants expressed negative opinions about this patient group

and suggested their views were similar to those held by

most other healthcare professionals:

I think if you ask most nurses and doctors and they were truthful

I’d probably say that nurses’ attitudes towards IV drug abusers and

illicit drug use and, think they’re a waste of space. I think that’s

what they’d say. I think they’re something we have to tolerate.

(Nurse 22)

The patient participants recognized this intolerance and

this seemed to fuel a confrontational mode of communica-

tion as a consequence:

I was coughing up a load of blood, I’d lost a lot of blood and the

doctor said ‘We want to put some blood in you, you’d better come

in.’ ‘No problem, yeah.’ And this nurse came up and was one I had

words with previously ‘Why should we waste a bed on you, you

type of people?’ You know what I mean. So that was it, I went

nuclear! [Became verbally and physically violent] (Patient 12)

The patient participants saw the perceived lack of knowl-

edge of illicit drugs as both a threat to their care and an

opportunity for exploitation. In effect, it afforded an oppor-

tunity to negotiate higher doses of methadone to control

the side effects of withdrawal. Conversely, it appeared to

impact on the care received when symptoms related to

withdrawal went unnoticed. This ‘lack of knowledge’ of

withdrawal management was reportedly well known among

the local community of drug users. A consequence of this

informal knowledge was that patient participants antici-

pated bad withdrawal experiences as a likely consequence

of admission to hospital. Another effect of this informal

knowledge was delaying admission to hospital irrespective

of severity of physical condition(s). The perceived risk of

unsupported withdrawal – ‘cold turkey’ – was seen as a

greater threat than delayed medical intervention.

On admission, patient participants saw the active negotia-

tion of methadone and related medication with healthcare

staff a priority for avoiding withdrawals. The negotiations

about methadone dosage usually began on admission to the

A&E department and if unresolved demands were escalated

on transfer to inpatient care (Medical wards/MAU). Persis-

tence was seen as a strategy for ensuring medication was

administered on time and/or prescriptions dose increased.

Persistence as a tactic was recognized as a risky strategy as it

could lead to conflict with medical and nursing staff. Persis-

tence frequently culminated in the patient being perceived as

a nuisance and interfering with the smooth running of the

ward. Persistence and escalation of demands seemed to serve

to reinforce negative attitudes. The patient participants

reported becoming increasingly discontented when with-

drawal was not managed effectively. This dissatisfaction

often escalated until a point where the patient ‘kicked off’

(Patient 11/Nurse 6). Kicking off involved displaying uncon-

trolled aggression towards the nurse(s) and confirmed the

view that these patients were disruptive and difficult to man-

age.

If these strategies failed, a response was to leave the ward

to ‘score and use’ (Patient 10) and/or take self-discharge:

They’ll (PDUs) come on the ward and 2 hours later they’re gone.

Because all they’re gonna get is DFs (Dihydrocodeine) andmaybe a bit

of Valium (diazepam). You know what I mean. Whereas if they had a

policy where if somebody says they’re on methadone, say somebody

comes in and they say ‘Well, I’m on methadone and I’d like 80 mL of

methadone a day’. ‘Alright, fair enough, I’m prepared to give you

40 mL of methadone today, 40 mL of methadone in the morning and

then we’ll ring your doctor’. You can have half of it. Always half it

because you can guarantee there’ll be a bit of blagging thrown in.

They’re not gonna stay, they’ll just walk off. And the trouble is when

they walk off is the time they (PDUs) drop dead. (Patient 12)

Another aspect of ‘lack of knowledge’ was the absence of

professional understanding of the clinical manifestations of

particular drugs:

I saw a girl come into the department, she’d been smoking crack

cocaine all day. She was screaming, she was really off her face,

she’d had too much crack, too much rock. Screaming, running up

and down the corridors: ‘Help me, help me, help me’. So they

started to put her onto a trolley. But they couldn’t understand


R. Monks et al.

while she wouldn’t keep still and rationally talk, they thought she

was just trying to get a f….ing shot of Valium. Know what I mean?

But she was totally off her face. The nurses and doctors just didn’t

see, they were blind to it. They don’t understand rock (crack

cocaine). (Patient 12)

‘Lack of knowledge’ also had an impact on other aspects

of normal nursing care such as the initiation of supportive

patient education:

Surely we should be doing something while they’re here. You

would with any physical illness which is caused by lifestyle, if it

was an MI, your health promotion, you would be using that. But

with IV drug use, all we do is say, ‘You shouldn’t do it’, But

because we don’t have an understanding, I can’t, I can’t offer nurs-

ing care or information to these people. (Nurse 20)

RNs appeared to be better attuned to patients who could

accurately describe their needs and appeared truthful; in

effect could engage in reciprocal engagement. By contrast,

interactions with patients with a history of illicit drug use

were conducted through a veil of mistrust with the patient

cast as untrustworthy and engaged in ‘blagging’ (Nurse 1).

Blagging was the term used to describe attempts to gain

something, in this case prescribed medication from a nurse

or doctor, by presenting a convincingly truthful explana-

tion. This strategy has been described in other studies, as

has the portrayal of the PDU as a ‘cheater’ (Chan et al.

2008), a foe, socially incompetent, and contemptible (Hill

2010). The perception of PDUs as inherently dishonest

appeared to reinforce negative stereotypes and validate pro-

fessional behaviour.

In the nurse interviews, there was an awareness that a

link existed between poor knowledge and social judgement:

Yeah, helping me to understand a little bit more about their addic-

tion as well because I think we’re all very guilty at times of being

quite judgmental, aren’t we? I think we’re all guilty of judging.

Well, I know I certainly am. (Nurse 25)

Most of the nurses interviewed acknowledged they per-

sonally, and other healthcare staff, held negative attitudes

towards patients who used illicit drugs. This seemed to

cause some dissonance for the nurses a consequence of the

friction between competing values. The RNs expressed

familiarity with the NMC Code of Professional Conduct

(NMC 2008, p. 2). This states that nurses should: ‘make

the care of people your first concern, treating them as indi-

viduals and respecting their dignity’. They also recognized

that their perceptions gained from contact with PDU’s were

incongruent with the professional code as they struggled to

see the person in the patient. This has been described as

‘othering’ patients and significant in obstructing any identi-

fication with patient vulnerabilities or needs (Benner et al.

2008). This dissonance was excused by lack of formal edu-

cation and training and regularly reinforced experientially

through exposure to this patient group. The nurses inter-

viewed in this study expressed a willingness to improve

their knowledge to provide better care and offered a range

of ideas for improving the formal educational preparation

for RNs (Table 5), but none suggested they should take

personal responsibility for acquiring that knowledge.

The absence of ‘knowledge to care’ meant the nurses in

this study seemed unable and sometimes unwilling to

engage in sustained interaction with these patients. Thus,

the behaviours described were at odds with the professional

code, ‘that one must not allow someone’s complaint to pre-

judice the care you provide for them’ (NMC 2008, p. 7).

The nurses seemed to reduce the emotional distress this dis-

sonance caused them by adopting several cognitive and

behavioural strategies. This involved distrust becoming the

assumption underscoring care giving and engaging in

detached manner towards PDUs as strategies to reduce con-

flict. The effectiveness of detachment and distrust went

unquestioned.

Distrust and detachment

Interactions with patients who used illicit drugs were emo-

tionally charged and steeped in mutual feelings of distrust.

This led the nurses in this study to minimize interactions

with PDUs and adopt a disconnected manner. Patient

participants recognized these features in interaction and

reacted by becoming increasingly antagonistic towards the

nurses and others members of the medical team.

Distrust was described as the basis for most interactions

with patients who used illicit drugs, manifesting itself as the

adoption of a detached way of being. Nurses reported limit-

ing the amount of time and interactions with patients who

Table 5 Educational preparation suggested by RNs.

● Understanding of the addiction process

● How the common illicit drugs work and affect people

● Insight into recognizing withdrawals and what to look for

● Courses of managing violence and aggression

● Reflection on case scenarios of previous illicit drug user

admissions

● Insight into the working of the Community Drugs Team

(CDT)

● Understand users’ views of being a patient in the medical ward

● How negative attitudes potentially affect management delivery

● What it is like to be a drug user



used drugs in comparison with other inpatients. The conse-

quence of this mutual distrust was an escalation of negative

behaviour, which on occasions ended in conflict involving

verbal or physical abuse directed towards the nurses and

other members of the healthcare team. On other occasions,

it resulted in enforced or self-discharge of patients prior to

resolution of their medical problem(s). Enforced discharge

seemed to be linked to implementation of ‘zero tolerance’

policies used with service users who engage in aggression

and/or violence towards staff (DH 2002). Limiting interac-

tion also meant that the nurses were not as sensitive to

patients’ needs, particularly in relation to their addiction

and associated problems. This detachment was described by

a nurse participant as caring for ‘aliens’ thus asserting their

‘otherness’:

We cannot offer ‘em anything, we can’t give ‘em anything, cos we

don’t know ‘em, to us they’re like ‘aliens’, cos we don’t know ‘em.

(Nurse 18)

Nurses also spoke of their reluctance to discuss issues

related to drugs, or drug use, while undertaking initial assess-

ments on admission to the ward. Lack of understanding of

drug use was offered as a reason for limiting the assessment

process. This reluctance was also recognized by patients who

felt the significance of information they provided went unap-

preciated or was not acted on. Patients described how they

made a rapid appraisal of the knowledge held by the health-

care team; any perceived naivety triggered increased medica-

tion negotiations. Some nurses spoke of purposely keeping

the initial assessment brief and focussed on the physical rea-

sons for admission. This superficial assessment created diffi-

culties for some patients as psychosocial issues related to

their addiction failed to emerge. This was significant as the

chaotic lifestyle of PDUs frequently impacted on individuals

whilst inpatients. Concurrent social and legal problems (e.g.

impending court appearances) often required urgent atten-

tion, and this sometimes led to patients absconding or precip-

itating self-discharge.

Emotionally draining

RNs expressed anxieties about interacting and delivering

care to patients with problematic drug use, particularly the

unpredictability of behaviour. Accounts of hostility and

how this interfered with the smooth running of the ward

contributed to the sub-category of detachment:

It’s hard, it is hard, the ward’s busy anyway and there are certain

people who do have these preconceived ideas and, you know, the

drug abusers are the bottom of heap, they get seen to last… When

they start kicking off and putting other people at risk and being very

very demanding, you do tend,…to detach from them. (Nurse 3)

Most RNs managing the care of patients who used illicit

drugs saw this as an emotional labour (Smith 1992, Smith &

Gray 2001). Nurses spoke of feeling more mentally tired and

drained when patients who use illicit drugs were inpatients.

The working environment was seen as one where intimida-

tion (from patients) was likely to be encountered, where the

RNs felt powerless especially when conflict, disruption, and

violence started to escalate in the confines of the ward:

They’re so unpredictable, you don’t know if they’re gonna sit down

and wait nice and bonny and think, or go off and start ranting and

raving, punching walls, shouting to all the other patients, you

know, like shouting at them as if it’s their fault as well, that

they’ve not got their methadone because they’re the ones that are

being sorted out with. You don’t know what’s gonna happen, it’s

really unpredictable and you fear sometimes, thinking, ‘This is gon-

na get really bad, we might have a really big situation here if we’re

not careful’, …’What do you do? What can we do?’ (Nurse 16)

Seeing the person behind the patient

In contrast, the small number of RNs (n = 3) theoretically

recruited to the study who were recognized in the organiza-

tion as experts in working with inpatient PDUs and drug

user friendly disclosed personal experiences of individuals

(family members or friends) who had used illicit drugs. This

personal biography, as opposed to professionally acquired

understanding, provided them with an insider perspective.

This appeared to positively influence attitudes and became

integrated into their professional way of working. These

RNs appeared to view the patients as people not as drug

users and they seemed more willing and able to interact

and deliver non-judgemental support:

I am interested in them. It’s just a personal thing to me, I have a

friend whose son is a heroin user, so it is interesting to me, but I

know some people, you know, they admit it, they’ve not got time

for them. A couple of times I’ve got involved with the family and

chatted to the family and hear their side of it. (Nurse 4)

The patient participants recognized those nurses who dis-

played emphatic behaviour towards them and responded

positively:

Q: You’ve got some nurses who are nice and they’re okay. And

you are nice and okay to them. (Patient 2)

There’s a young student nurse and she was changing m’bandage

earlier and I were telling her like what happened and that and she


R. Monks et al.

was like really taking interest…and she’s showed more like interest

than what all have ‘em have put together.. She’ll be a good nurse,

definitely. (Patient 4)

When a nurse appeared to show an interest in their prob-

lem, listen, and treat the patient as a ‘person’ not ‘problem

drug user’, interactions with members of the healthcare team

were less charged. The three nurses identified and recruited

to this study appeared to be able to develop rapport, work

with the PDU, and interact in a more recognizably engaged

way. The relationship with patients appeared to other nurses

and the PDUs as less dissonant and more congruent with the

ideology of caring and value of equity of care.

The sub-category ‘distrust and detachment’ illustrates

how in addition to lack of educational preparation and

negative attitudes towards patients who use illicit drugs,

personal experience also served to influence care delivery

and nurse–patient interactions. Seeing the person behind the

patient created an environment where interactions with

PDUs were more positive and harmonious.

Discussion

This study relied solely on interview data and an obvious

limitation is what people ‘say they do’ is not necessarily

‘what they do’ in practice. The nurses and the patients’

accounts confirmed each other and therefore notionally

acted as verification. The likelihood that nurse participants

would present themselves in a negative light if those

accounts were untruthful seems doubtful. Nevertheless, an

observational study would better illustrate how beliefs and

perceptions are transferred into behaviours during care

delivery and would be recommended in future work.

The two sub-categories jointly contribute to the account

of ‘dissonant care management of patients who use illicit

drugs’. The combination of lack of educational preparation

and negative attitudes appeared to act as a barrier to effec-

tive care giving. The RNs functioned in a state of antici-

patory arousal engendered by fears of disruption and

violence. This had the consequence of producing a way of

working that was dissonant with the values more com-

monly associated with nursing: such as competent care giv-

ing and relationships based on mutual trust. The nurses in

this study struggled to avoid the patient’s illness, PDU,

prejudicing the care they provided for them. Dissonance

was not solely a consequence of a relationship between a

lack of knowledge plus negative attitudes. This study

showed experience of caring for PDUs by maintaining them

at a distance as ‘other’ (Benner et al. 2008) appeared to

reinforce negative attitudes and provide knowledge that

constructed and maintained rather than dismantled the bar-

rier between the nurse and PDU.

A distinctive feature of nursing in the UK is that prepara-

tion for initial registration is divided into four branches or

specialities (Adult, Child, Learning Disabilities, and Mental

Health). Adult branch nursing students receive limited edu-

cational input about the health needs of mental ill health. A

potential consequence of specialization is that problem drug

use is categorized as largely falling in the domain of mental

health and positions the PDU outside adult nursing and

very definitely as ‘other’.

That said ‘otherness’ is not necessarily related to stigmati-

zation, exclusion, or demonization yet can result in judge-

ments about the social worth of an individual or group.

Evaluation is an attribute of humanness; hence, nurses are as

likely to make social judgements about a person’s worth as

anyone else. Johnson and Webb (1995) argued that moral

appraisal based on particular attributes, diagnosis, or social

class is more complex than merely labelling and judgements,

as ‘they are flexible and changeable, depending on the social

context’ (p. 471). In this study, the judgement of social worth

of patients admitted with complications of their drug use

seemed to be applied prior to any assessment of the person.

Moreover, such judgements signalled a blanket risk contrib-

uting to perceptions of distrust and use of detachment. How-

ever, this could be specific to this context, where pace and

complexity coupled with efficiency and throughput contrib-

uted to patient objectification, alienation, and constructions

of ‘otherness’.

Although nurses may fight to preserve personhood, it

must be challenging in a rapidly churning acute healthcare

environment (Duffield et al. 2009). Interestingly, those RNs

with personal knowledge gained from exposure to friends

and family members with problems associated with drug

use were able to engage in a different, possibly person-

centred, nurse–patient relationship. They were able to see

the person behind the patient and thus provide a more

caring role expected in the current ideology of nursing.

The primacy of the nurse–patient relationship in care

delivery is central to a contemporary ideology of nursing.

An element of this ideology is the importance placed on

the nurse knowing the patient. Most nurses in this study

spent little time getting to know these patients and, indeed,

minimized interaction as a strategy to reduce opportunities

for conflict and violence, a form of risk management. The

nurses’ spoke candidly of having less concern for patients

who used drugs, seeing their priority as those patients

admitted with supposedly more serious physical conditions

such as myocardial infarction and stroke. These patients



were seen as more worthy recipients of their care and

attention. In effect, patients admitted due to complications

of their drug use were prejudged and this impacted on the

care they received. This picture is in stark contrast to

McCance’s (2003) analysis of nurse caring attributes (e.g.

‘showing respect for patients’, ‘Being there’, and ‘being

attentive’); accordingly, the concept of dissonant care

emerged.

Emotional labour, a term first coined by Hochschild

(1983), has been embraced by many commentators (James

1993, Smith & Lorentzon 2007, Gray 2009), as a way of

explaining the trained response used by nurses for managing

and responding to the emotions of patients. It is part of the

labour of nursing work yet can engender feelings of stress,

anxiety, and influence the quality of nurse–patient relation-

ships (Firth-Cozens & Payne 1999). Nurses are obliged, like

many workers, to control their emotional responses within a

narrow range of appropriate behaviours and may feel conflict

between their genuinely felt emotions and those that are pro-

fessionally appropriate to display (Huy 1999). In this study,

most of the RNs consciously chose not to engage in emotional

work with PDUs. Detachment was used as a device for mini-

mizing opportunities. The patient participants recognized

‘part of the gossip’ that they might not receive emotional care

from the majority of RNs they encountered and, perhaps as a

consequence, chose not comply with expectations associated

with the patient role. Thus, a consequence of dissonant care

was neither party fully fulfilled the usual contract of social rec-

iprocity (Molm et al. 1999) in the nurse–patient encounter.

Nurses were aware of this and used several cognitive strategies

such as conflict minimization as a reason for this lack of inter-

action with PDU’s, a form of cognitive dissonance.

Festinger’s (1957) theory of cognitive dissonance suggests

that when behaviours are at odds with beliefs, individuals try

to reduce the psychological distress this causes by adopting

several cognitive and behavioural tactics. Thus, nurses may

seek to reduce their disquiet at being unable to fulfil their core

caring role or engage in emotion work with drug users’ needs

by labelling them as ‘difficult’, ‘problem’, and sometimes

‘alien’ patients.’ This behaviour allows the judgement that

these patients to be appraised as having less social worth and

the cause of their own misfortunes (Johnson 2003). Neverthe-

less, detachment did not seem to be successful defence against

anxiety possibly because of distrust engendered by fears of dis-

ruption and violence.

The findings presented in this study suggest that the con-

ceptual attributes of caring are dissonant to those described

as characterizing most nurse interactions with patients who

are admitted with complications of problem drug use;

moreover, this contributed to poorer outcomes for both the

patients and the nurses.

Conclusion

Findings in this study showed that care management pro-

vided to patients who use illicit drugs was often confused,

chaotic, and disruptive. Early orchestration of appropriate

medication to manage symptoms of withdrawal for PDUs

might offer a stable platform for establishing social

reciprocity as the basis for a person-centred approach.

Better communication between the community drug team

What is already known about this topic

● People with problematic drug use often require

unplanned admission to acute care hospital services

with physical complications of their drug use.

● People with problematic drug use often present with

coexisting psychosocial problems and chaotic social

circumstances that complicate any inpatient stay.

● Registered Nurses, in common with other health pro-

fessionals, often hold negative and stereotypic attitudes

towards patients who use illicit drugs.

What this paper adds

● Registered Nurses in this study recognized they lacked

competencies to manage the problem drug use associ-

ated needs of patients who use illicit drugs.

● Distrust and negative attitudes characterized the nurse

–patient relationship in this study.

● The lack of knowledge to care for problem drug users

coupled with distrust and detachment dominated the

nurse–patient relationship which led to care being

managed and delivered in a vacuum of suspicion and

confrontation.

Implications for practice and/or policy

● Registered Nurses working in acute care settings

require education and training to understand problem

drug use and addiction, to manage withdrawals and

related behaviour, and to initiate appropriate support

for patients who use illicit drugs.

● Understanding the person behind the problem drug

use and addiction may offer a key to care delivery.

● Curriculum development and delivery should involve

services users who have experience of problem drug

use.


R. Monks et al.

and hospital ward staff may aid this. The complexity of

managing and delivering care, the interplay between per-

ceptions, attitudes, and behaviour led to distance and esca-

lation of distrust between the nurses and patients.

According to the nurses’ accounts, education might

improve care management of patients who use illicit drugs

and this need integrating into the Adult branch nurse cur-

riculum in the UK. What was strikingly different in the

accounts provided by the participants was the term

‘expert’ RNs’. These were RNs who gained powerful

learning from personal exposure to people who used illicit

drugs. Arguably non-professional knowledge contributed to

recognizable empathetic professional behaviour and more

positive attitudes towards PDUs. The involvement of ser-

vice users (people who use illicit drugs) in any educational

initiatives may help to expose nurses, to see the person

behind the drugs and ultimately enable RNs to manage

and delivery more competent and empathetic care to this

patient group. Education initiatives alone may not suffice

to rectify the problems encountered when patients who use

drugs clash with the individual nurse; however, such initia-

tives might offer exposure to strategies to de-escalate con-

flict and be more understanding of the plight of PDUs

when they enter the medical ward.

These recommendations may enhance the assessment of

addiction, the management of withdrawals, and the emo-

tional aspects of care provided to patients with problematic

drug use. This could have the effect of reducing the rates of

conflict, unsupported withdrawal from opiate drugs, and

enforced or self-discharge of patients with potentially life-

threatening physical complications.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors meet at least one of the following criteria (rec-

ommended by the ICMJE: http://www.icmje.org/ethi-

cal_1author.html) and have agreed on the final version:

● substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

● drafting the article or revising it critically for important

intellectual content.

References

Benner P., Sutphen M., Leonard-Kahn V. & Day L. (2008)

Formation and everyday ethical comportment. American Journal

of Critical Care 17(5), 473–476.

Boyle M.J., Williams B., Brown T., Molloy A., McKenna L.,

Molloy E. & Lewis B. (2010) Attitudes of undergraduate health

science students towards patients with intellectual disability,

substance abuse and acute mental illness: a cross-sectional study.

Medical Education 10(71), 4–8.

Carroll J. (1995) The negative attitudes of some general nurses

towards drug misusers. Nursing Standard 9(34), 36–38.

Carroll J. (1996) Attitudes to drug users according to age of staff.

Professional Nurse 11(6), 401–404.

Chan K.T., Stoove M.A. & Reidpath D.D. (2008) Stigma, social

reciprocity and exclusion of HIV/AIDS patients with illicit drug

histories: a study if Thai nurses’ attitudes. Harm Reduction

Journal 5(28), 1–11.

Cooke M.W., Higgins J. & Kidd P. (2003) Use of emergency

observation and assessment wards: a systematic literature review.

Emergency Medicine 20, 138–142.

Deehan A., Taylor C. & Strang J. (1997) The general practitioner,

the drug misuser and the alcohol misuser: major differences in

general practitioner activity, therapeutic commitment and ‘shared

care’ proposals. British Journal of General Practice 47(424),

705–709.

Denzin N.K. & Lincoln Y.S. (2003) Introduction: The Discipline

and Practice of Qualitative Research. Sage, Thousand Oaks.

Department of Health (2002) Withholding Treatment from Violent

and Abusive Patients in NHS Trusts: NHS zero tolerance zone.

Department of Health, London.

Duffield C., Diers D., Aisbett C. & Roche M. (2009) Churn: patient

turnover and case mix. Nurse Economics 27(3), 185–191.

European Monitoring Centre for Drugs and Drug Addiction (2005)

The State of the Drug Problem in the European Union and

Norway: Annual Report 2005. European Monitoring Centre for

Drugs and Drug Addiction, Lisbon.


The State of the Drug Problem in the European Union and

Norway: Annual Report 2006. European Monitoring Centre for

Drugs and Drug Addiction, Lisbon.


The State of the Drug Problem in the European Union: Annual

Report 2010. European Monitoring Centre for Drugs and Drug

Addiction, Lisbon.

Festinger L. (1957) A Theory of Cognitive Dissonance. Stanford

University Press, Evanston.

Firth-Cozens J. & Payne R. (1999) Stress in health professionals.

Health and Stress 16(5), 327–329.

Foster J. & Onyeukwu C. (2003) The attitude of forensic nurses to

substance using service users. Journal of Psychiatric & Mental

Health Nursing 10(5), 578–584.

Godfrey C., Eaton G., McDougall C. & Culyer A. (2002) The

Economic and Social Cost of Class A Drug Use in England and

Wales, 2000. Home Office, London.

Gray B. (2009) The emotional labour of nursing: defining and

managing emotions in nursing work. Nurse Education Today 29

(2), 168–175.



Happell B. & Taylor C. (2001) Negative attitudes towards clients

with drug and alcohol related problems: Finding the elusive

solution. Australian & New Zealand Journal of Mental Health

Nursing 10(2), 87–96.

Harling M. & Turner W. (2012) Student nurses’ attitudes to illicit

drugs: a grounded theory study. Nurse Education Today 32(3),

235–240.

Harling M., Overy C., Beckham G., Denby R., Goddard S.,

O’Connor C., Piotrowski E., Prout T. & Tully D. (2006)

Addressing negative attitudes towards substance use in nursing: a

peer-led approach in nurse education. Drugs and Alcohol Today

6(2), 38–41.

Heyes P.D. (2002) Substance abuse integration in nursing

education: an innovative collaborative model. Substance Abuse

23(1), 67–79.

Hill T.E. (2010) How clinicians make (or avoid) moral judgments

of patients: implications of the evidence for relationships and

research. Philosophy, Ethics and Humanities in Medicine 5(1),

1–14.

Hochschild A. (1983) The Managed Heart. University of California

Press, Berkeley.

Huy Q.N. (1999) Emotional capability, emotional intelligence

and radical change. The Academy of Management Review 24(2),

325–345.

James N. (1993) Divisions of Emotional Labour: Disclosure and

Cancer. In Communication, Relationships and Care (Barett S.,

Komaromy C., Robb M. & Rogers A., eds), Routledge, London,

pp. 259–269.

Johnson M. (2003) Nurses, clients and power. In Sociology as

Applied to Nursing and Health Care, Chapter 8 (Birchenhall M.

& Birchenhall P., eds), Bailliere Tindall, Edinburgh.

Johnson M. & Webb C. (1995) Rediscovering unpopular patients:

the concept of social judgement. Journal of Advanced Nursing

21(3), 466–475.

McCance T.V. (2003) Caring in nursing practice: the development

of a conceptual framework. Research and Theory for Nursing

Practice: An International Journal 17(2), 101–116.

McLaughlin D.F., McKenna H. & Leslie J.C. (2000) The

perceptions and aspirations illicit drug users hold toward health

care staff and the care they receive. Journal of Psychiatric &

Mental Health Nursing 7(5), 435–441.

Molm L.D., Peterson G. & Takahashi N. (1999) Power in

negotiated and reciprocal exchange. American Sociological

Review 64(6), 876–890.

Morrison E.F., Ramsey A. & Synder B.A. (2000) Managing the

care of complex, difficult patients in medical-surgical settings.

MEDSURG Nursing 9(1), 21–26.

Nursing and Midwifery Council (2008) The Code of Professional

Conduct. NMC, London.

Rassool H.G. & Rawaf S. (2008) Predictors of educational

outcomes of undergraduate nursing students in alcohol and drug

education. Nurse Education Today 28(6), 691–701.

Rassool H.G. & Salman R. (2008) Education intervention of

undergraduate nursing students’ confidence skills with alcohol

and drug misusers Education intervention of undergraduate

nursing students’ confidence skills with alcohol and drug

misusers. Nurse Education Today 28(3), 284–292.

Richards L. (2000) Using NVivo in Qualitative Research. QSR

International Pty, Victoria.

Smith P. (1992) The Emotional Labour of Nursing. MacMillan,

London.

Smith P. & Gray B. (2001) Emotional labour of nursing revisited:

caring and learning 2000.Nurse Education in Practice 1(1), 42–49.

Smith P. & Lorentzon M. (2007) Is emotional labour ethical.

Nursing Ethics 16(6), 638–642.

Strauss A. & Corbin J. (1998) Basics of Qualitative Research:

Techniques and Procedures for Developing Grounded Theory.

Sage, Thousand Oaks.

UK Focal Point (2004) United Kingdom Drug Situation 2004:

Annual Report to the European Monitoring Centre for Drugs and

Drug Addiction (EMCDDA). Centre for Public Health, Liverpool

John Moores University and Department of Health. ????.

United Nations Office on Drugs and Crime (2010) World Drug

Report 2010. United Nations, Vienna.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of

evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance

and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original

research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal and with an Impact Factor of 1·540 – ranked 9th of 85 in the 2010

Thomson Reuters Journal Citation Report (Social Science – Nursing). JAN has been in the top ten every year for a decade.

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries

worldwide (including over 3,500 in developing countries with free or low cost access).

• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.

• Positive publishing experience: rapid double-blind peer review with constructive feedback.

• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.

• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley

Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).


R. Monks et al.

Documents

The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: a grounded theory study