Exploring nurses’ experiences of caring for people who inject drugs with a physical health condition: an integrative literature review
Intended for healthcare professionals
Evidence and practice    

Exploring nurses’ experiences of caring for people who inject drugs with a physical health condition: an integrative literature review

Jenny Hayden Practice nurse, Lion Health, Stourbridge, England

Why you should read this article:
  • To think about your role in caring for people who inject drugs (PWID) presenting with a physical health issue

  • To recognise how listening to personal stories about drug addiction can enhance nursing care of PWID

  • To consider how you can adopt a more compassionate and trauma-informed approach to the care of PWID

The physical health risks associated with intravenous drug use are well documented and include infective endocarditis, deep vein thrombosis, transmission of blood-borne viruses and bacterial skin infections. With illicit drug use increasing, nurses are more likely to provide care to people who inject drugs (PWID). However, there is little research focusing on nurses’ experiences of providing care for PWID with a physical health condition.

This article details an integrative literature review that was undertaken to explore nurses’ experiences of caring for PWID with a physical health condition and to determine the factors that affect these experiences, with a view to identifying knowledge gaps in current practice. Four main themes were identified: lack of knowledge, emotional challenges, stigma, and fear and safety. Overall, the review found that nurses often feel educationally unprepared to care for PWID, and therefore require training, education and ongoing support to reduce stigma towards this patient group and to ensure they receive high-quality nursing care.

Primary Health Care. doi: 10.7748/phc.2024.e1816

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

jenkenn4@gmail.com

Conflict of interest

None declared

Hayden J (2024) Exploring nurses’ experiences of caring for people who inject drugs with a physical health condition: an integrative literature review. Primary Health Care. doi: 10.7748/phc.2024.e1816

Published online: 06 March 2024

Background

Illicit drug use in the UK is increasing, and consequently there has been a rise in drug-related mortality, especially in relation to intravenous (IV) drug use. In 2022 there were 4,907 drug-related deaths in England and Wales, with almost half of these involving opiates – most frequently heroin and morphine (Office for National Statistics 2023). The increase in drug use has been exacerbated by factors such as the coronavirus disease 2019 (COVID-19) pandemic, poverty, unemployment, inequalities and mental health conditions, along with disruptions to drug treatment service provision (United Nations 2021). Additionally, spending on drug treatment services in the UK has been cut by an average of 27% since 2015-2016 (Grierson 2020). The government’s efforts to address drug use have been met with scepticism, with critics claiming that the From Harm to Hope strategy (HM Government 2023) demonises people who misuse drugs and fails to propose any new measures to reduce drug-related mortality (Holland et al 2023).

It is estimated that there are approximately 87,000 people who inject drugs (PWID) aged 15-64 years in the UK, heroin being the most commonly injected drug (UK Health Security Agency 2023). Heroin, also known as diacetylmorphine or diamorphine, is a strong analgesic derived from the opium poppy (Roden 2009). Users of heroin report feelings of intense euphoria, especially when it is used intravenously. Heroin is highly addictive due its chemical effect on the brain – an increase in levels of the ‘happy hormone’ dopamine – leading to overwhelming cravings and increased drug use (Tolomeo et al 2021). Consequently, PWID can experience increasing financial pressure and often turn to criminality to raise money for buying drugs (Geraghty 2018). The National Crime Agency (2023) estimated the overall cost of illicit drug use – including drug use itself, drug seizures and drug-related offences – in the UK at more than £21 billion per year. However, it is also important to recognise the human cost of illicit drug use.

There are numerous physical health risks associated with IV drug use, often due to unhygienic preparation combined with suboptimal injection technique. These risks include infective endocarditis, deep vein thrombosis, transmission of blood-borne viruses and bacterial skin infections, all of which can result in premature mortality (Coull et al 2021). Additionally, a potential increase in the transmission of blood-borne viruses among the drug-using community has been reported. This is likely due to the COVID-19 pandemic, which led to reduced drug treatment service provision and difficulties in accessing clean injecting equipment, meaning that sharing needle equipment among PWID may have increased (Whitfield et al 2020). The number of people presenting to primary and secondary healthcare settings for treatment related to drug misuse is also increasing; for example, the number of people admitted to hospital for poisoning by drug misuse in 2019/2020 was 9% higher compared with 2012/2013 (NHS Digital 2021).

McClelland (2006) maintained that nurses should regard caring for people who misuse drugs as an opportunity to help them address their drug use and offer support in terms of recovery. However, PWID often feel apprehensive about accessing healthcare and often leave potentially treatable physical health concerns until hospital admission is required, due to perceived stigmatisation by healthcare professionals (van Boekel et al 2013).

To accurately determine the prevalence of stigma towards PWID, it is important to explore nurses’ experiences of caring for PWID with a physical health condition. Little research has focused solely on nurses’ experiences of caring for PWID, instead concentrating on the experiences of drug users, therefore this gap in research requires further investigation (Horner et al 2019). Nurses are in a unique position to recognise and support this patient group, since PWID are more likely to engage with nurses than with other healthcare professionals (Moore 2019). Consequently, the role of nurses is influential in promoting harm reduction and preventing illness associated with injecting drug use, as well as in encouraging recovery from addiction.

This article details an integrative literature review on nurses’ experiences of caring for PWID with a physical health condition that the author undertook as part of an end-of-year project for their master’s degree in adult nursing.

Aim

To explore nurses’ experiences of caring for PWID with a physical health condition and to determine the factors that affect these experiences, with a view to identifying knowledge gaps in current practice.

Method

An integrative literature review was used to enable a critical appraisal of existing research, discover potential gaps in current knowledge and make recommendations for practice (Christmals and Gross 2017). This secondary research method enables a combination of diverse methodologies – for example, experimental and non-experimental research, as well as empirical and theoretical sources – to be used to examine a phenomenon (Whittemore and Knafl 2005).

Search strategy

The author conducted systematic searches of the MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus and Google Scholar databases between December 2021 and January 2022. These databases were selected because they all contain a wealth of literature related to nursing practice.

To strengthen the search results, Boolean operators were applied to almost every search, for example ‘nurse OR nurses OR nursing’. Wildcard characters and advanced searches were also implemented to enhance the relevance of results (Aveyard 2014). A wide range of terms was used in relation to injecting drug users, including ‘intravenous drug user’, ‘opioid use disorder’ and ‘people who inject drugs’.

The searches were filtered to four countries – Australia, Canada, the UK and the US – since these are all developed countries where English is the main language. To ensure the literature found was relevant to the review topic, the searches were also filtered based on subject heading, year of publication (2000-2021) and specific nursing roles. Adult nurses working in emergency departments, intensive treatment units and the community were included, as well as nursing students. Mental health, learning disability and children’s nurses were excluded because they are unlikely to care for PWID with a physical health condition.

Key points

  • People who inject drugs (PWID) are at risk of physical health issues that can result in premature mortality

  • PWID are often reluctant to access healthcare services because of perceived stigmatisation

  • Nurses may lack the knowledge required to care for PWID with a physical health condition, particularly regarding the treatment of opiate withdrawal

  • Education and training are crucial in enhancing nurses’ experiences of caring for PWID and subsequently improving outcomes for this patient group

Searching was ceased once the same articles appeared again in the searches, which indicated that no new results were emerging (Aveyard 2014).

Critical appraisal and thematic analysis

The quality of the articles was evaluated using Critical Appraisal Skills Programme (CASP) (2024) checklists. The CASP offers a structured method for critiquing research and was chosen because of its clear and unambiguous questions prompting critical thinking (CASP 2024). One article was deemed inappropriate for inclusion in the review after applying the CASP checklist had shown that it lacked clarity regarding its methodology.

Braun and Clarke’s (2006) approach to thematic analysis was identified as an appropriate tool to guide the identification of themes because it can enable novice researchers, such as the author, to extract and organise material from the selected articles (Nowell et al 2017). Coding was initially conducted using coloured pens and note taking. Participant quotes from the qualitative studies were identified to support and add meaning to the themes (Braun and Clarke 2006).

Findings

Six articles were selected for inclusion in the review. Five of the articles used a qualitative approach (Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, McCall et al 2019, Todt and Thomas 2021) and one article used a quantitative approach (Norman 2001). The predominance of qualitative data was deemed useful, since finding out about the subjective experiences of nurses was fundamental to the aim of the review (LoBiondo-Wood and Haber 2013). Table 1 provides a summary of the included articles and is available online at: rcni.com/injecting-drugs

Four main themes were identified from the literature:

  • Lack of knowledge.

  • Emotional challenges.

  • Stigma

  • Fear and safety.

Lack of knowledge

Lack of knowledge was a theme that influenced nurses’ experiences of caring for PWID with a physical health condition, and it appeared in all five qualitative articles included in the review (Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, McCall et al 2019, Todt and Thomas 2021). For example, one nurse interviewed in Monks et al’s (2013) study stated:

‘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 nursing care or information to these people.’

In particular, nurses reported feeling unprepared when it came to recognising and treating withdrawal symptoms of opioid use, namely heroin. One nurse in Horner et al’s (2019) study described the internal conflict they experienced when caring for PWID:

‘You are kind of at war with yourself as a nurse, being like “am I just going to medicate you because you’re a drug addict and you’re looking for it?”.’

This highlights a lack of knowledge in relation to the treatment of opiate withdrawal, which may also cause the nurse to question the legitimacy of symptoms such as acute pain and to be reluctant to provide analgesics.

Nurses in two of the articles expressed a desire for training and education specifically in relation to the medical management of individuals displaying withdrawal symptoms (Monks et al 2013, Horner et al 2019). These nurses suggested that enlisting people recovering from drug addiction to provide training for staff would help emphasise the person behind the drug misuse.

The district nurses interviewed in Peckover and Chidlaw’s (2007) study appeared to transfer responsibility for the care of PWID to their mental health nurse colleagues:

‘I think it’s because we don’t deal with a lot of that, it’s usually dealt with by the drug people or the [community psychiatric nurse], something like that. We are sort of on the periphery, doing other things.’

‘I wouldn’t really know much about how… like going to help them, other than, perhaps, referring to the mental health services, and that probably would be as far as my remit would go.’

Consequently, improving nurses’ education regarding PWID, especially managing opiate withdrawals, is a complex task and should be based on evidence-based clinical guidance. However, nurses require multidimensional support from their healthcare organisation, managers and colleagues to better understand, and provide appropriate care for, PWID.

Emotional challenges

Emotional challenges was a theme that arose in three articles (Horner et al 2019, McCall et al 2019, Todt and Thomas 2021). One challenge reported by nurses was not seeing the physical health of PWID improve, which caused them to feel conflicted because they could not fulfil the perceived expectations of their professional role. For example, one nurse in Todt and Thomas’s (2021) study stated:

‘That’s what we’re meant to do… Make things better than we found it. It really is hard for the nurse to accept… the choice of another person to be [at] harm to themselves.’

As a result, some nurses explained that they felt detached from PWID because they viewed their regular presentations to healthcare services as ‘a repetitive process’ and deemed becoming invested in supporting their recovery as futile (Horner et al 2019, Todt and Thomas 2021). One nurse in Horner et al’s (2019) study said:

‘Sometimes the psychosocial aspect of knowing that they’re going to go back out and do this all over again… it’s not just a burden on the patient, but it’s a burden on the caregivers too, knowing what the possible outcomes are.’

Contributing to nurses’ frustrations was the belief that physical health complications among PWID were ‘self-inflicted’. For example when discussing patients who develop infective endocarditis because of IV drug use, one nurse in Todt and Thomas’s study (2021) said:

‘If you play stupid games, you’re going to win stupid prizes.’

In contrast, nurses who witnessed improvements in the health of PWID reported positive experiences of caring for these patients, with one nurse in McCall et al’s (2019) study saying:

‘Seeing people get unionized jobs as front desk workers… It’s pretty amazing because you look at these people, they were having to sell their bodies, you know, crime, whatever to get their next fix. And now they’re able to have some stability.’

It appears that nurses’ experience of caring for PWID with a physical health condition is often influenced by patients’ outcomes. Caring for PWID seems to cause internal conflict for nurses at times, since their aim to improve patients’ health is challenged when caring for this group.

Stigma

Examples of stigma were identified in four articles, predominately involving nurses stigmatising PWID (Norman 2001, Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019). Nursing students who participated in Norman’s (2001) study were asked to describe a photograph of a man injecting drugs, and many used terms such as ‘weak’ and ‘stupid’. These descriptions reveal the negative emotional reactions that injecting drug use can elicit. These nursing students may subsequently transfer these discriminatory attitudes into the workplace once they become registered nurses. In Todt and Thomas’s (2021) study, some nurses referred to PWID as ‘the dreaded patient’, while one nurse in Monks et al’s (2013) study stated that many nurses think PWID and illicit drug users are ‘a waste of space’.

Stigma and the perception of blame are closely linked and were evident in five articles (Norman 2001, Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, Todt and Thomas 2021). Nurses reported hearing their colleagues say ‘Well, they did it to themselves’ when caring for patients who had developed infective endocarditis as a result of IV drug use (Todt and Thomas 2021). Interestingly, McCall et al’s (2019) study revealed that nurses who care for PWID can experience stigma from their colleagues, with one nurse explaining that they were:

‘Being constantly questioned, like, “Why are you working [at the opiate assisted treatment clinic] – when are you going back to the hospital?” As if I should be doing something different and something better, in their terms.’

However, listening to the harrowing life experiences of PWID enabled nurses to feel more empathetic towards these individuals, which reduced stigma. This was expressed by one nurse in McCall et al’s study (2019):

‘I think having a more personal understanding of the level of trauma that these folks have experienced in their life and how that has contributed to their addicted lifestyle. It’s just allowed me to be more compassionate about it, that, that’s the biggest thing.’

Similarly, nurses who expressed feeling compassion and empathy towards PWID were the nurses who had personal experience with addiction or a special interest in caring for that patient group (Horner et al 2019):

‘Well, addiction runs in my family… I think it definitely helps being educated on it, because I find I have more compassion. And treat it as a disease, and not as they’re trying to be difficult.’

In summary, stigma appears to be reduced when nurses are able to listen to and understand patients’ lived experience of their addiction. This appears to address the negative perception that drug misuse is a ‘choice’ and may therefore lead to improvements in the therapeutic relationship and patient care.

Fear and safety

Feeling fearful of potentially aggressive and challenging PWID was a theme identified in four articles, with nurses providing accounts of calling security and adopting avoidance tactics on hospital wards and in the community (Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, Todt and Thomas 2021). For example, a district nurse in Peckover and Chidlaw’s (2007) study reported:

‘From the experiences that we’ve had, it can be sort of the aggression. The aggression that can come if they’re not getting the drugs that they want… that is quite daunting, quite scary.’

However, many nurses failed to provide examples of violence from PWID towards staff, suggesting that this fear may be unwarranted in some cases. A district nurse in Peckover and Chidlaw’s (2007) study described the actions that were taken when a patient in the community became angry after he had not been prescribed his methadone hydrochloride correctly:

‘So then we went in twos after that, even though it didn’t really warrant it once he’d settled down. But I think the stigma was there and it was, “We’d better go in twos just to be on the safe side”.’

One strategy that reduced hostility and improved the therapeutic relationship between nurses and PWID was the use of open and honest communication. Nurses in two articles reported better patient outcomes and increased job satisfaction when treatment and boundaries were discussed with patients from the outset (Peckover and Chidlaw 2007, Horner et al 2019). One district nurse in Peckover and Chidlaw’s (2007) study provided the following example:

‘So he comes to me at the clinic. And when he came, I just said, “Look, don’t mess us about.” I was not judgemental. But it has worked really well. It is not just me, there is another nurse who works there as well. And we have done it together. It is working in partnership.’

Nurses reported that if pain and analgesics were discussed from the person’s initial presentation to healthcare services, this would reduce any false hope that they might receive opiates which could meet the needs of their addiction (Horner et al 2019). This could reduce patients’ frustration and the risk of potential altercations that can affect nurses’ feelings of fear and safety when caring for PWID with a physical health condition.

Discussion

The findings of this integrative literature review reveal that nurses often feel educationally unprepared to care for PWID with a physical health condition, with emotional challenges, stigma, fear and safety concerns appearing to originate from this lack of education. Therefore, training that focuses on PWID and addiction is essential to improve nurses’ experiences and consequently improve patient care.

The findings of this review suggest that nurses’ compassion and empathy towards PWID increase through listening to personal stories about how their drug use began, facilitating a deeper understanding of the factors surrounding addiction and reducing stigma, fear and safety concerns (Monks et al 2013, Horner et al 2019, McCall et al 2019). By listening to the patient, nurses were able to see the person behind the drug addiction. People recovering from drug addiction can provide unique insights and knowledge due to their personal experience and expertise, so their involvement in recovery-focused enterprises has been urged (Public Health England 2015). As a result, nurses could benefit from training delivered by people with personal experience of addiction (Goddard et al 2021).

This review has clearly identified that nurses need to improve their knowledge about addiction and the medical management of opiate withdrawal. Consequently, if nurses could access a standardised training programme that incorporated caring for PWID and providing trauma-informed care, this would improve nurses’ knowledge and develop their understanding and compassion regarding the factors that influence addition. Trauma-informed care shifts the focus from ‘What’s wrong with you?’ to ‘What happened to you?’ (Trauma-Informed Care Implementation Resource Center 2021), so it could change some nurses’ attitudes from stigmatising and blaming the person towards a more compassionate approach.

Substance misuse is intrinsically linked with exposure to trauma (Mills 2015). Therefore, access for nurses to education on trauma-informed care is essential for providing holistic care to vulnerable patient groups such as PWID. A study by Cannon et al (2020) found that trauma-informed care training for preregistration nurses improved their knowledge and skills, and increased their awareness of how trauma affects patients’ physical, mental and spiritual health. If the government allocated funding from the From Harm to Hope (HM Government 2023) drugs strategy to provide trauma-informed care training for nursing students, the likelihood of nurses experiencing the issues identified in this review might be reduced.

Limitations

As a novice researcher, the author found the integrative literature review process complex and challenging, and the scarcity of literature on the topic of nurses caring for PWID with a physical health condition protracted the process. In addition, the focus was on literature from Australia, Canada, the UK and the US, so important and influential studies from other countries may have been omitted. The review showed that there is little primary research on nurses’ experiences of caring for PWID with a physical health condition, so further research is necessary to explore this subject on a wider scale.

Implications for practice

The findings of this integrative literature review revealed that PWID are at risk of receiving suboptimal care from nurses due to a lack of knowledge about addiction (Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, McCall et al 2019, Todt and Thomas 2021). Since illicit drug use is increasing and the UK is witnessing an emergence of synthetic opiates (West Mercia Police 2023), education for nurses and the wider healthcare team needs to improve if issues such as lack of knowledge, emotional challenges, stigma and fear are to be addressed. If healthcare professionals’ training needs are neglected, the physical health of PWID is at risk and their reluctance to seek healthcare will increase further (Geraghty 2018). Healthcare professionals and organisations need to address the lack of education and confidence in caring for PWID and regard this as equally as important to other training requirements for patient groups such as people with dementia or diabetes mellitus.

It is disappointing to learn from this review that some nurses are stigmatising PWID and providing suboptimal care to these patients (Peckover and Chidlaw 2007, Monks et al 2013, Horner et al 2019, Todt and Thomas 2021). This contradicts the principles of The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) (2018). For example, the Code states that nurses must make sure that ‘any discriminatory attitudes and behaviours towards those receiving care are challenged’. However, many nurses address these issues by requesting training and education on caring for PWID and managing opiate withdrawal symptoms (Monks et al 2013, Horner et al 2019). Nurses could improve their knowledge by spending time in drug treatment services and with substance use teams as part of their continuing professional development (NMC 2021). It is important that training is supported at managerial and organisational levels to ensure successful implementation (Chaghari et al 2016).

Nurses have a professional responsibility to remain adequately trained and competent in their field of practice, and to ensure that they act in accordance with the relevant ethical and legal principles of nursing (NMC 2018). The role of nurses has changed over the years, with the historical notion of nurses being ‘doctors’ handmaidens’ long gone (Middleton 2018). Nurses are now able to become autonomous practitioners, for example advanced nurse practitioners can diagnose and prescribe for patients. This means that nurses’ role in caring for PWID is more important than ever. Day et al’s (2011) study revealed that PWID often preferred to consult nurses rather than doctors because nurses were more approachable and accessible. Receiving relevant training and education will assist nurses to adopt a more compassionate and trauma-informed approach to the care of PWID, while also enabling them to act as leaders and role models.

Conclusion

This integrative literature review found that many nurses have insufficient knowledge regarding opiate addiction and withdrawal, resulting in suboptimal care for PWID with a physical health condition. Related issues such as emotional challenges, stigma, fear and safety concerns were also identified. Organisational improvements in relation to training and education could enhance nurses’ experiences of caring for PWID and lead to better outcomes for this patient group.

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