Accepted Manuscript Undergraduate nursing students

Accepted Manuscript
Undergraduate nursing students' experiences and attitudes
towards working with patients with opioid use disorder in the
clinical setting: A qualitative content analysis
Laura F. Lewis, Lauren Jarvis
PII: S0260-6917(18)30913-4
DOI: https://doi.org/10.1016/j.nedt.2018.11.001
Reference: YNEDT 4008
To appear in: Nurse Education Today
Received date: 24 July 2018
Revised date: 11 October 2018
Accepted date: 2 November 2018
Please cite this article as: Laura F. Lewis, Lauren Jarvis , Undergraduate nursing students'
experiences and attitudes towards working with patients with opioid use disorder in
the clinical setting: A qualitative content analysis. Ynedt (2018), https://doi.org/10.1016/
j.nedt.2018.11.001
This is a PDF file of an unedited manuscript that has been accepted for publication. As
a service to our customers we are providing this early version of the manuscript. The
manuscript will undergo copyediting, typesetting, and review of the resulting proof before
it is published in its final form. Please note that during the production process errors may
be discovered which could affect the content, and all legal disclaimers that apply to the
journal pertain.

ACCEPTED MANUSCRIPT
Research Paper
UNDERGRADUATE NURSING STUDENTS’ EXPERIENCES AND ATTITUDES TOWARDS WORKING WITH
PATIENTS WITH OPIOID USE DISORDER IN THE CLINICAL SETTING: A QUALITATIVE CONTENT ANALYSIS
Laura F. Lewis, RN, PhD
University of Vermont, USA
Lauren Jarvis, RN, BSN
MedStar Georgetown University Hospital, USA
Corresponding Author:
Laura Lewis
University of Vermont Nursing Department
216 Rowell Building, 106 Carrigan Drive
Burlington, Vermont 05405
Email: [e-mail]
Phone: [phone]
Acknowledgements:
This work was supported by the University of Vermont Honors College. The authors wish to thank the
participants of this study for their willingness to share their experiences with us.
Contribution Statement:
L.J. conceived of the idea, conducted all interviews, analyzed findings, and drafted a thesis on which this
manuscript was based. L.F.L. supervised the research process, co-analyzed data, and wrote the
manuscript.
Conflict of Interest:
The authors declare that they have no conflicts of interest.
Word Count: 4,996
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Undergraduate nursing students’ experiences and attitudes towards working with patients with opioid use
disorder in the clinical setting: A qualitative content analysis
Abstract
Background: With the US facing an opioid epidemic, undergraduate nursing students are increasingly
encountering patients with opioid use disorder in the clinical setting. Yet, nursing curriculums have not
adapted to meet this need. Previous research indicates students are exposed to negative messages that
might influence their views about patients with opioid use disorder.
Objectives: The purpose of this study was to examine nursing students’ experiences encountering
patients with opioid use disorder in the clinical setting, their attitudes about their encounters, and their
perceptions of their educational preparedness to care for this population.
Method: Purposive sampling was used to identify participants. Semi-structured interviews were
conducted until saturation. Krippendorff’s method for qualitative content analysis was used to cluster
units within the data to identify emergent themes.
Participants: Eleven senior nursing students from a public university in New England participated.
Results: Analysis revealed six themes, including: navigating ethical dilemmas, gaining comfort with time
and experience, avoiding the “elephant in the room,” learning from real-world scenarios, witnessing
discriminatory care, and recognizing bias and stigma.
Conclusions: Students were most likely to experience bias and internal conflict in maternity clinical
rotations. Education should include practical communication strategies to reduce avoidance behaviors
among nursing students as well as techniques to manage difficult situations and reduce moral distress.
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Nurses must be mindful of their power to influence students and should model non-judgmental language
and behavior. Students ultimately expressed a desire to provide informed and empathetic care.
Keywords:
Students, nursing; substance use disorders; opioid; qualitative studies; content analysis; education,
nursing, baccalaureate; education, clinical
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
More than 63,600 people in the United States died from drug overdose in 2016, and
approximately 66% of those cases involved an opioid (Centers for Disease Control & Prevention,
2017). This number has increased fivefold since 1999, indicating an epidemic of opioid use
disorder [OUD]. Patients with OUD present across care settings (Bartlett et al., 2013), and
nursing students encounter these patients during clinical rotations. Despite increased prevalence,
OUD education is insufficiently incorporated into nursing school curriculums (Finnell et al.,
2018).
The purpose of this qualitative content analysis was to explore nursing students’
experiences and attitudes about caring for patients with OUD during clinical rotations and to
assess their perceptions of their educational preparedness in working with this population.
Review of Literature
A review of literature from the last 10 years on CINAHL and PubMed yielded limited
research on nursing students’ perceptions about substance use disorder [SUD], including OUD.
In a grounded theory of UK nursing students’ attitudes about SUD, researchers concluded that
students encountered persistent negative messages that would likely influence their care of these
patients (Harling & Turner, 2011). Some quantitative studies exploring nursing students’
attitudes about patients with SUD indicate negative biases and low empathy (Aggarwal, Ghai, &
Basu, 2012; Harling, 2017), while others reveal non-judgmental and positive views about
working with patients with SUD (de Vargas, 2012; Pereira et al., 2018). None of these studies
focused specifically on OUD, and none took place in the US.
Studies exploring registered nurses’ attitudes about patients with SUD indicate an
overarching culture of negativity in healthcare. A systematic review of 28 articles on the
attitudes of health professionals revealed that participants felt patients with SUD were difficult to
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
care for due to manipulative, violent, and unsafe behaviors, and professionals viewed patients as
responsible for their conditions (van Boekel et al., 2013). These negative attitudes directly
affected patient care. For example, nurses in one study in this review demonstrated an avoidance
approach towards patients with SUD, and another study found patients who perceived
discrimination were less likely to complete treatment.
Similarly, Daibes et al. (2016) found nurses in addictive rehabilitation centers in Jordan
exhibited stigma, marginalizing, avoidance, and discriminatory behaviors towards patients.
Other studies also suggest that nurses generally have neutral or negative views towards caring for
patients with SUD, often citing insufficient training and poor role support as contributing factors
(Chu & Galang, 2013; Neville & Roan, 2014).
Inexperienced nursing students may learn poor practices by modeling behaviors and
language of nurses who have not been appropriately trained which may perpetuate stigma,
misinformation, and improper care. Perceptions of nursing students must be examined to tailor
educational interventions prior to their initiation into practice. In this study, researchers aimed to
provide a richer understanding of nursing students’ views by providing an opportunity for
students to describe their actual patient encounters and their thoughts and feelings about those
experiences.
Methods
The purpose of this study was to answer the research questions:
1) What are the experiences and attitudes of undergraduate nursing students working with
patients with OUD?
2) How prepared do nursing students feel to care for this population?
Ethical Considerations
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
This study was approved by the University IRB. Recruitment and interviews were
conducted by an undergraduate nursing student trained in qualitative research to limit coercion
and response bias. The faculty co-researcher was not responsible for clinical oversight of
eligible participants at any point during their education. Students were notified that participation
would have no impact on their grades. Informed consent was obtained prior to all interviews.
Data Collection
Purposive sampling was used to recruit senior nursing students at a public university in
New England. Recruitment posters were placed in a nursing building on campus and an
announcement about the study was made during a required senior nursing course. Semi-
structured interviews were conducted in locations convenient for participants. Table 1 illustrates
the interview guide. Interviews were audio-recorded and transcribed verbatim. Interviews were
conducted until saturation of new information was reached.
TABLE 1 HERE
Data Analysis
Krippendorff’s method for qualitative content analysis through “clustering” was used to
analyze data (2013). This method allowed researchers to make inferences from interview
transcripts by grouping data “based on intuitively meaningful similarities among units of
analysis” (Krippendorff, 2013, p. 206). It also allowed researchers to explore student interviews
in a broad sense, looking not only at the meaning of their experiences but also on their feelings
of preparedness and their suggestions for nursing education.
Transcripts of interviews were broken down into “units” based on thematic distinctions.
Units were words, phrases, or sentences that described a single idea. Units were clustered, which
involved “forming perceptual wholes from things that are connected, belong together, or have
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
common meanings” and continued until there was no content remaining to merge together
(Krippendorff, 2013, p. 206). Clustering was illustrated by dendrograms, or tree-like diagrams,
depicted in Figure 1.
FIGURE 1 HERE
Rigor and Trustworthiness
Lincoln and Guba’s (1985) evaluative criteria were used to establish trustworthiness.
After independent analysis, findings were reviewed and discussed in-depth with a co-researcher
and resorted until consensus was reached. Member-checking occurred by sharing and discussing
findings with two participants. Both participants felt findings were representative of their
experiences and did not recommend any changes.
Results
Eleven senior nursing students participated in this study. Participants were 20-23 years
old and all were White females. In total, 497 units were extracted from transcribed interviews
and clustered to reveal six themes: 1) navigating ethical dilemmas; 2) gaining comfort with time
and experience; 3) avoiding the “elephant in the room”; 4) learning from real-world scenarios; 5)
witnessing discriminatory care; and 6) recognizing bias and stigma. The following sections will
describe each theme.
Navigating Ethical Dilemmas
Participants faced significant ethical dilemmas when working with patients with OUD.
Most described encounters as “hard” and “difficult.” Participants described particular challenges
assessing and treating pain. This was further complicated because they lacked control in their
limited roles as students. One participant cared for a patient post-operatively where the patient
was yelling out in pain but requesting specific medications only. She shared:
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
It was really hard as a student because I didn’t have much say in what happened, but I
was also concerned, because how do you differentiate between what’s real pain that he’s
feeling from surgery and what’s manipulative or abusive behavior? [06]
Another participant shared an experience where she struggled to focus on preparing a
patient’s pain medications because the patient continuously interrupted to request the
medications faster. She described challenges identifying an appropriate dose, and ultimately
administered a dose that she felt was inappropriate and possibly even dangerous:
Looking at her and knowing that her respiration rate was two we still had to give her
methadone and on top of that she wanted her IV Dilaudid and it’s literally going to stop
your breathing and you still want this. … I felt uncomfortable taking care of that patient.
[04]
Students also described internal conflicts related to patient privacy, especially in the
maternity setting. For example, one participant was asked to conceal a mother’s OUD from her
partner. She shared:
The mother hadn’t told the father that there was any type of substance use going on so the
baby was born addicted, and the baby was actually in a study about pupil size after birth
with [OUD], and the father had no idea that was going on. So that was kind of difficult. I
felt like that was ethically wrong. [02]
Another participant shared a similar experience:
I worked with a patient who had delivered her baby and the baby was in the [neonatal
intensive care unit] because of [neonatal abstinence syndrome] scoring and she didn’t
want her significant other to know why the baby was there and that she had been using
and all these things. So it was an interesting dynamic where it’s her patient information
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
so you can’t tell, but it’s the other guy’s baby so he should know. It’s just like, what’s
the right thing? [03]
Participants were left questioning their own actions and the actions of the healthcare team.
Gaining Comfort with Time and Experience
Participants described first encounters with patients with OUD as “uncomfortable,”
“overwhelming,” “awkward,” and “sad.” One participant reflected on her first encounter, “I
mean it was our first clinical rotation and everything was so new and it was like wow this is
some crazy shit” [03]. When asked if she felt comfortable with OUD, another participant
responded, “I would say no, especially not that first rotation. … I think it’s definitely a little bit
overwhelming if you’re assigned a patient with substance use disorder” [07]. Another described
witnessing a situation where a patient deliberately deceived a nurse and said, “It was like, very
awkward from my experience. And, like, unsettling. Because I was like, oh my God what just
happened?” [11].
While a majority of participants indicated they felt uncomfortable caring for patients with
OUD, some felt more comfortable with time and experience. One participant said, “I wouldn’t
say that I’m totally prepared but as I went through school I become more comfortable with it”
[05], and another, “I think I got more comfortable as I went on” [07]. One described how a
challenging experience with OUD prepared her to work with future patients: “Even having
[OUD] patients after that specific patient I felt prepared” [11]. Students gained comfort as they
were able to improve their skills through experience.
Avoiding the “Elephant in the Room”
When asked how they would identify if a patient had OUD, 4 out of 11 participants
indicated they would rely on the chart or shift report rather than assessing the patient. When they
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
were aware the patient had OUD, participants indicated they were uncomfortable addressing it
due to inexperience and lack of knowledge. One participant explained:
I never actually talked to them about their addiction and I never talked to them about their options
of what they do from here. Like do they go to rehab? What do they do in rehab? They detox and
then they go to counseling? Like I don’t really know necessarily how that process works and so I
guess I feel uncomfortable talking to my patients about it because like, how do you bring it up
you know? Is it in your head to toe assessment when you’re like, look at your track lines. Like,
so, you’re a user huh? And it’s just kind of like awkward, and it’s almost like the elephant in the
room. [09]
Another participant described her experience providing smoking cessation education to a young patient
admitted after a heart attack with illicit drugs in his system. She described that it was challenging “just
trying to like portray myself as knowledgeable and mature about substance abuse when he has obviously
had more experiences than me out in the world with substance abuse” [10].
Other participants shared a similar lack of comfort and confidence in their skills. One said:
I didn’t feel like I had the language or communication skills at that point to sit down and talk to
them about their substance abuse and what their life looks like… and I don’t know … how to
bring up this tricky conversation and what words are right and how to not be offensive. [03]
Concern that discussion about OUD would appear “offensive” or “accusatory” was especially present
when working with patients with suspected OUD. One participant reported that she did not discuss
treatment options with a patient with suspected OUD and reflected, “It’s hard to say if I would’ve felt
comfortable with that because it seems accusatory if they don’t have an established addiction that we are
aware of. So I don’t know. It’s a hard thing to maneuver” [05]. Without feeling comfortable to discuss
OUD, students failed to address their patients’ holistic needs.
Learning from Real-World Scenarios
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Participants were knowledgeable about signs and symptoms of OUD but indicated they
did not know how to approach patients in real-life settings. As one participant shared, “We
learned the symptoms of [OUD], but I wouldn’t say that we necessarily learned how to actually
deal with them” [04]. Another suggested using simulation to learn about OUD and said:
I honestly don’t feel like my nursing program really prepared me for any type of
conversation I’d have about substance abuse. … I think more of a hands on experience is
better than reading it or being presented to by PowerPoint because you can’t really get a
good feel for how you might react unless you’re actually talking to someone. [02]
Four students reported that talking to individuals with OUD positively changed their
perspectives. One said: “I think the most beneficial thing was caring for somebody and seeing a
lived experience of the opioid addiction because you talk about it over and over and over and
you get it and empathize with these people when you hear stories about them in class” [08].
Another said, “That was really helpful having the point of view and listening to their struggles
from their side and how they got to this point in their life. Because no 13-year-old is sitting there
like, I’ll probably use heroin someday” [04]. These participants felt a guest lecture would be a
powerful educational experience. Others suggested use of case studies, watching videos,
participating in outpatient programs, and learning how to manage their own biases.
Participants also addressed timing of education. Most students encountered OUD in their
first clinical rotation in the maternity setting, and many perceived this was the rotation where
OUD was most prevalent. Participants wished they received education prior to this rotation. One
participant said, “I do feel like the education came a little too late and we should’ve had a lot
more education about that during mom and baby when we were working with those patients”
[03], and another, “During the first rotation we were definitely not prepared” [07]. Participants
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
desired more specific knowledge as well. For example, when asked what improvements she
would suggest, one participant said, “…Talking through like what interventions will look like
and not just saying, like okay we send them to rehab. Like what do they do there?” [04].
When asked about harm reduction, several students were able to define it and engage in
conversation about risks and benefits. These participants reported that discussion-based teaching
was effective and memorable. Others indicated that instructors “briefly touched upon it” but felt
they needed more education [01, 04, 05], and one demonstrated a lack of understanding of harm
reduction [02].
Participants expressed a desire for more education on OUD. One student said, “I feel
that’s definitely a part that [nursing schools] should expand on because it’s becoming a more and
more prevalent issue in the United States and we’re going to be seeing it a lot more in the clinical
setting” [01]. Another said, “I know there’s tons of other material to cover, but I do feel that
under the current circumstances of the opioid problem in [this area] there should be more” [09].
Witnessing Discriminatory Care
Participants reflected on messages they received from nurses in the clinical setting. One
participant shared the positive influence that nurses had on her views about OUD:
I think also another good thing was having a couple of nurses like as my mentors who
were not judgmental towards those patients who showed empathy towards them. Not just
in the room when you’re like, okay like I know that they can have a good bedside manner
but might think whatever they want to in the hallway, or say whatever they want to to
other nurses in the hallway, but they genuinely cared and they genuinely were concerned
and wanted to get the patient help. And they were the ones saying it’s not their fault that
they’re manipulative in this way doing what they think they have to in order to get what
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
they need. And so I’d say that was probably the most beneficial was seeing other people
that didn’t have a negative attitude and negative bias towards them in healthcare. [04]
Another described a clinical rotation where nurses provided information without judgment: “I
think that the nurses did a good job explaining the [neonatal abstinence syndrome] score and
giving the students as much information about opioid withdrawal without, you know, having
judgments” [07].
Unfortunately, these same participants described scenarios where nurses demonstrated
negative biases that affected patient care. One participant described asking a nurse about
appropriate dosages of pain medication and shared:
My nurse would also kind of brush it off and be like well she’s manipulative, oh she’s an
addict. And so it’s hard when you have the person, your mentor, the person you’re going
to is also brushing off certain care aspects. [04]
Another described shadowing a nurse caring for an infant with neonatal abstinence syndrome:
The nurse had a lot of biases about that mother. I as a [nursing student] hadn’t really
encountered that open sharing of those biases. I saw how they inhibited her ability to
care for the patient and provide all the education that she was providing to her other
patients that day. [09]
One summarized, “In the mother baby setting I felt more uncomfortable there because of how the
nurses stigmatize the patients in that setting” [08]. These encounters with nurses made
participants feel even more uncomfortable in situations where they already lacked skills and
confidence.
Recognizing Bias and Stigma
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Eight of eleven participants recognized that they experienced bias towards a patient,
particularly in maternity. One said, “I think we all say we wouldn’t have any judgment towards
the patient, but I’d say holding a newborn baby and knowing the mother willingly put them
through that, it’s a bit difficult” [02]. The use of the word “willingly” reflects an implicit belief
that OUD was a choice. Another reported her struggle to view OUD as a disease:
I definitely did have some sort of bias toward these mothers. I mean, they’re not
choosing this drug over their child. They don’t have that option because they physically
can’t, but it was difficult trying to make myself think and feel and understand that it’s not
their choice, it’s this disorder that they have. [01]
Some participants admitted that they blamed mothers for symptoms in newborns, using
the phrase, “How could you?” when considering the mother’s actions [04, 09, 11]. One said, “I
realized that addiction is a disease … but my compassion for people who are addicted – it wavers
a bit when there’s a baby involved” [05]. Another shared:
It was hard to remain non-judgmental and still provide quality care to the mom and not
say, like, look at the baby and be like, this is the mother’s fault. She’s to blame, she did
this to her baby, how could she? [04]
One student’s perspective changed after becoming involved in an outpatient substance-abuse
program for pregnant women:
In the inpatient setting, I was thinking, “How could you do this to your child?” and
“You’re not gonna be a good mother as you worry about all of your own substance abuse
problems.” … But I will say working with mothers at that program has really made me
realize how much they love and care for their children, and I think that is something that
was sort of lacking in my view before. [09]
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Participants also struggled with bias related to manipulative behaviors and trust. One participant
said, “It’s just so hard to still take care of them in the same way. I just don’t trust them as much” [04].
Another shared:
I think there’s some stigma especially with IV drug use and people assuming they’re uneducated
or aren’t motivated, or some character biases I can see myself falling into sometimes. I think
maybe subconsciously it may have affected how I treated them. But I felt like I was reflective
enough to step back and realize what I was thinking about. [06]
While participants admitted bias, they also demonstrated empathy and a desire to be non-
judgmental. When asked about most beneficial aspects of her education, one participant
summarized, “I would say probably understanding that this could happen to anyone. Like it’s
not a lifestyle, how you’re raised, it’s not who you are – the substance use disorder doesn’t
define you. It can happen to anybody anywhere” [01].
Discussion
Six themes emerged that described the attitudes, experiences, and preparation of nursing
students caring for patients with OUD, including facing ethical dilemmas, increasing comfort
with experience, avoiding discussion of OUD, preferring education with real-world applicability,
observing nursing bias, and recognizing their own biases. Findings were consistent with previous
research showing that health professionals experience difficulty and discomfort caring for
patients with SUD, leading to avoidance and missed opportunities for intervention (Daibes et al.,
2016; van Boekel et al., 2013), but previous studies have not explored these phenomenon in
student nurses. This study further adds evidence about students’ preferences for education on
OUD and the impact of nursing role models on students. Despite facing challenges, participants
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
in this study expressed a desire to provide informed and empathetic care, a readiness to learn,
and an attempt to identify and reduce their own biases.
One noticeable trend in this study was the impact of encountering OUD in the maternity
setting. Students perceived OUD was most common in this population, yet there is no evidence
to support this. One possible explanation is that students had increased awareness of OUD due
to patient disclosure or symptoms witnessed in newborns. This was also the first clinical rotation
for students in this sample, which may have caused these experiences to be more memorable.
In addition, students felt these situations led to bias and internal conflict more often than
other settings. Qualitative studies on the experiences of registered nurses caring for childbearing
women with OUD and their newborns reveal similar findings, where nurses face “difficult”
situations and feel concerned about the capacity of mothers with OUD to care for their babies
(Maguire et al., 2012; Shaw et al., 2016). Nurse educators can assist students in preparing for
ethical dilemmas and minimizing moral distress by using group debriefing about values and
experiences, discussion of real scenarios as case studies, and meditative writing (Sasso et al.,
2016). Future research should also replicate this study with students who enter the maternity
rotation later in their clinical curriculum for comparison to determine optimal order of
placements to reduce students’ biases and perceptions of ethical distress.
Findings also suggest that students require content training on OUD prior to entering the
clinical setting, particularly before maternity rotations. Participants desired specific and realistic
education, such as using simulation as a safe environment to enact a difficult conversation or
dilemma. Simulation has been shown to have a positive impact on knowledge and performance
(Orique & Phillips, 2018). Practicing real conversations in educational settings might also help
students gain confidence and limit avoidance in the practice setting.
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Participants also suggested strategies such as sharing the lived experiences of those with
OUD and coordinating shadow experiences in treatment centers. Shadowing experts in OUD
may expose students to positive healthcare role models, which could help diminish the power of
negative role models students will likely encounter in other settings. By incorporating real life
experiences of individuals with OUD in the curriculum, nurse educators may assist students in
developing empathy and understanding when working with this population. Future research
should explore the effects of educational interventions such as simulation, guest lecture, and/or
shadowing integrated prior to the maternity rotation on reducing bias and improving knowledge
and self-efficacy.
Students also recalled minimal education on harm reduction, which offers nurses the
opportunity to provide education about topics such as overdose prevention, management in case
of an overdose, phlebotomy, and prevention and management of common comorbidities such as
hepatitis C and human immunodeficiency virus (Bartlett et al., 2013). Nursing students are well
positioned to bring awareness of harm reduction strategies to the practice setting as they become
professionals, and early education may help mitigate stigma and bias.
Participants’ accounts added evidence that stigma, bias, and discrimination are present in
the clinical setting. The impact of bias on patient care has been documented (Daibes et al., 2016;
van Boekel et al., 2013), but this study highlights a further consequence of bias as it influences
nursing students and potentially their future practice. Nurses must be mindful of the power of
their words and actions on students and recognize that this influence persists even outside the
patient’s room. Nurses should embrace the opportunity to be positive role models by providing
students with information without judgement and encouraging empathy and understanding.
Limitations
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
This study included participants from one university in New England. All participants
were White females of similar ages. Findings reflect a limited geographic and cultural context.
Further research is needed to explore attitudes of nursing students in other regions in the US.
Participants were interviewed by a fellow classmate, which may have influenced responses,
though this might also be considered a strength as participants felt comfortable sharing openly
with the student researcher. Self-selection to participate in this study may have biased findings,
as students who felt most strongly about OUD would be those most likely to participate.
Conclusion
This qualitative content analysis revealed that nursing students’ attempt to work through
ethical dilemmas and personal discomfort as they care for patients with OUD in the clinical
setting. Students often avoid discussion of OUD and witness discriminatory behaviors by
nurses. Participants offered honest reflections on their own assumptions and expressed a desire
to overcome internal biases. They reported that real-world discussions, simulations, and
interactions were most effective in promoting empathy and acquiring practical knowledge for
working with patients with OUD. Given the growing prevalence of OUD and the potential
impact of bias on care of these patients, nurse educators must answer the call to address a
significant gap in nursing curriculum to improve delivery of care and patient outcomes.
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
References
Aggarwal, M., Ghai, S., & Basu, D. (2012). Attitude of nursing students towards psychoactive substance
use: Does training matter? International Journal of Nursing Education, 4(2), 146-150.
Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2013). Harm reduction: Compassionate
care of persons with addictions. Journal of MedSurg Nursing, 22(6), 349-358.
Centers for Disease Control & Prevention. (2017). Opioid overdose: Understanding the epidemic.
Retrieved from: https://www.cdc.gov/drugoverdose/epidemic/index.html
Chu, C., & Galang, A. (2013). Hospital nurses’ attitudes toward patients with a history of illicit drug use.
The Canadian Nurse, 109(6), 29-33.
Daibes, M. A., Al-Btoush, M. S., Marji, T., & Rasmussen, J. A. (2016). Factors influencing nurses’
attitudes towards patients in Jordanian addiction rehabilitation centres: A qualitative study.
International Journal of Mental Health and Addiction, 15(3), 588–603. doi:10.1007/s11469-016-
9682-2
de Vargas, D. (2012). Nursing students’ attitudes towards alcohol, alcoholism and alcoholics: A study of
a Brazilian sample. Journal of Nursing Education and Practice, 2(1), 1-8. doi:
10.5430/jnep.v2n1p1
Finnell, D. S., Savage, C. L., Hansen, B. R., Sanchez, M., White, K. M., Johnson, J. A., & Seale, J. P.
(2018). Integrating substance use content in an “overcrowded” nursing curriculum. Nurse
Educator, 43(3), 128-131. doi:10.1097/nne.0000000000000438
Harling, M. R. (2017). Comparisons between the attitudes of student nurses and other health and social
care students toward illicit drug use: An attitudinal survey. Nurse Education Today, 48, 153-159.
doi: 10.1016/j.nedt.2016.10.012
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Harling, M. R., & Turner, W. (2011). Student nurses’ attitudes to illicit drugs: A grounded theory study.
Nurse Education Today, 32, 235-240. doi: 10.1016/j.nedt.2011.05.002
Krippendorff, K. (2013). Content analysis: An introduction to its methodology. Thousand Oaks, CA:
Sage.
Lincoln, Y. & Guba, E. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage Publications.
Maguire, D., Webb, M., Passmore, D., & Cline, G. (2012). NICU Nursesʼ Lived Experience. Advances in
Neonatal Care, 12(5), 281–285. doi:10.1097/anc.0b013e3182677bc1
Neville, K., & Roan, N. (2014). Challenges in nursing practice: Nurses’ perceptions in caring for
hospitalized medical-surgical patients with substance abuse/dependence. Journal of Nursing
Administration, 44(6), 339–346. doi:10.1097/nna.0000000000000079
Orique, S. & Phillps, L. (2018). The effectiveness of simulation on recognizing and managing clinical
deterioration: Meta-analyses. Western Journal of Nursing Research, 40(4), 582-609.
Pereira, S. C. C., Andreto, L. M., Souza, A. I., Frazao, I. S., Rassool, G. H., & Pillon, S. C. (2018).
Knowledge and perceptions of undergraduate nurses towards the use of cocaine (smoked) in a
Brazilian context. Archives of Psychiatric Nursing, 32(3), 348-352. doi:
10.1016/j.apnu.2017.11.024
Sasso, L., Bagnasco, A., Bianchi, M., Bressan, V., & Carnevale, F. (2016). Moral distress in
undergraduate nursing students. Nursing Ethics, 23(5), 523–534. doi:10.1177/0969733015574926
Shaw, M. R., Lederhos, C., Haberman, M., Howell, D., Fleming, S., & Roll, J. (2016). Nursesʼ
Perceptions of Caring for Childbearing Women who Misuse Opioids. American Journal of
Maternal/Child Nursing, 41(1), 37–42. doi:10.1097/nmc.0000000000000208
Van Boekel, L. C., Brouwers, E. P. M., van Weeghel, J., & Garretsen, H. F. L. (2013). Stigma among
health professionals towards patients with substance use disorders and its consequences for
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1-2), 23–35.
doi:10.1016/j.drugalcdep.2013.02.018
ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT
Table 1. Interview guide
Interview Questions
1. How would you know if someone was addicted to opioids?
2. Could you describe any experiences you had working with opioid dependent
patients in the clinical setting? Please share any thoughts, feelings, and specific
memories you have about these experiences in as much detail as possible.
3. How comfortable did you feel caring for these patients? How comfortable did
you feel discussing opioid addiction and treatment options when working with
this patient?
4. Can you discuss some biases that you may have when working with this
population? How do you feel these biases may have affected your delivery of care
to the patients?
5. Tell me about your education in regards to opioid addiction and treatment options
that you know of. How prepared did you feel to work with opioid dependent
patients in the clinical setting?
6. What education did you receive about harm reduction? What are your thoughts on
it?
7. What was the most beneficial in terms of education you received about opioid
addiction while in nursing school?
8. What suggestions or modifications would you make to the education you received
about opioid addiction while in nursing school?
ACCEPTED MANUSCRIPT

Figure 1