Kelleher S, Cotter P. A descriptive study on emergency department doctors' and nurses' knowledge and attitudes concerning substance use and substance users. Int Emerg Nurs. 2009;17(1):3-14.
INTRODUCTION
Emergency departments have become an appropriate setting for the detection of substance-using patients. Health care professionals' knowledge and attitudes can play a role in the failure to identify and address patients with substance-use problems and may negatively influence the care that these patients receive. The purpose of this study is to determine emergency department doctors' and nurses' knowledge and attitudes regarding problematic substance use and substance users.
The research, derived from a study of emergency departments within Ireland, is current, logical, and clear. Currently in Ireland, there is no evidence to indicate health care professionals' success in detecting substance-using patients. Internationally, 75% of substance-using patients pass through emergency departments undetected.
The author identifies a knowledge gap in detecting substance abusers who present to the emergency department. However, this study's literature review does not refer or state that there is a gap when providing knowledge to the reader of past systems to detect substance abusers.
STUDY METHODS
This study utilizes a survey design with the research question: What is the knowledge and attitude of emergency department doctors' and nurses' regarding problematic substance abusers? The sample is a care group that consists of all emergency department doctors and nurses (N = 145) working in 3 university teaching hospitals in Ireland, with a response rate of 46% (n = 66). Participants completed a survey questionnaire, which focused on the training needs of community-mental health workers in managing clients who misuse alcohol and other drugs.
The questionnaire focuses on participants' demographic characteristics, training, educational qualifications, and professional experience, designed to examine 6 objectives:
* Current level of knowledge regarding substance use
* Perceived level of knowledge regarding patients with substance-use problems
* Perceived level of competence in managing patients with substance-use problems
* Attitudes regarding substance use; attitudes regarding patients with substance-use problems. This measurement is complete by utilizing a substance-abuse attitude survey (SAAS)
* Perceived roles in managing patients with substance-use problems
* Frequency of interactions with patients who present to the emergency department, exhibiting signs and symptoms of substance use
Ethical approval consists of permission from relevant medical directors, directors of nursing, and an ethics committee who provide permission to proceed with the research.
RESULTS
The results of the study indicate that emergency department doctors and nurses care for substance users on a daily basis and identify a role in their assessment and education. The majority of participants, however, do not receive any specific training regarding alcohol and other drugs. Regarding the SAAS, the results of the study suggest that doctors and nurses working in emergency departments exhibit near-optimal attitudes in all subgroups, with the exception of permissiveness, for constructive working with substance-using patients. Despite participants' lack of specialist or in-service training, the study results indicate that their current level of knowledge about alcohol and drug use, in general, is satisfactory.
The participants feel confident in their knowledge concerning alcohol use and dependence; there is a significant lack of confidence regarding the use and dependence of other substances.
The respondents suggest that substance-using patients are managed inadequately; they identify a shortage of services to treat this patient group as being the primary impediment to adequate management rather than a lack of specific knowledge or training. Past studies that have investigated mental health professionals' attitudes found that their attitudes were predominantly suboptimal. In contrast, the sample of emergency department doctors and nurses demonstrated near-optimal attitudes.
Three major strengths were identified in this study. (1) An allotment period of 4 weeks between questionnaire dissemination and collection to each department provides a comfortable amount of time for participants to fill out the questionnaires. (2) Questionnaires were collected by means of a "drop-in box" located centrally in each of the departments, which gives the participants a sense of anonymity. (3) The study did have a valid research question to answer.
This helps fulfill a critical need in producing best care practice toward substance-abusing patients. Three weaknesses within this research study were identified as follows. (1) This study is conducted in 1 geographical area in southern Ireland with a small sample size. (2) Participants identify the questionnaire as being lengthy and time-consuming. This may have affected both the response rate and the submission rate of incomplete questionnaires. (3) The SAAS self-ratings by doctors and nurses may cause an unrealistic subjective self-rating.
GENERAL COMMENTARY
The utilization of this study can be the first tool to treat substance abusers within emergency departments across the entire United States. An unwritten consensus exists within emergency departments regarding (1) medical stability and (2) disposition in a timely manner, whether this disposition is admitting a patient to an inpatient status, or discharging a patient.
It is the medical attention that takes top priority within the emergency structure. The social behaviors, in contrast, which may cause many medical issues, get very little attention. This provides a symptomatic approach rather than a disease approach. For example, if a patient with a complaint of right lower quadrant abdominal pain with rebound tenderness, vomiting, fever, and generalized malaise arrives to the emergency department, the practitioner will not stop at treating just the symptoms with narcotics, antiemetics, and antipyretic. The practitioner will order laboratory tests and most likely a computed tomographic scan of the abdomen and pelvis to rule out appendicitis to look for the root cause of these symptoms. However, when practitioners fail to recognize behaviors of substance abuse, which may in fact cause many repeat emergency department visits, they fail to determine symptomatic root causes in which the patient presents.
In contrast, emergency department caregivers do an adequate job of identifying substance abusers when a patient presents with pain-control issues such as chronic back pain, and who admits to self-administering large doses of narcotics to control their pain issues. Like this research, this study suggests that practitioners will be less likely to prescribe an additional narcotic for this patient, whether it is during the emergency department stay, or as an outpatient prescription. These patients are usually discharged with instructions to follow up with their primary care provider or a pain management specialist. However, they are not automatically provided information to seek follow-up care for their narcotic dependence.
In both of these cases, the underlying cause is untreated, and inadequate management for these substance abusers exists. There is a need for emergency department caregivers to enhance their knowledge in identifying and treating substance-abusing patients. Furthermore, there is a bigger need for organizations to establish competencies, which will cover signs and symptoms of substance abuse, common diseases substance abusers present with, and a proper protocol for adequate treatment of these substance abusers.