The impact of knowledge on attitudes of emergency department staff towards patients with substance related presentations: a quantitative systematic review protocol.

CENTER CONDUCTING THE REVIEW: University of Manitoba and Queens Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute

REVIEW QUESTION/OBJECTIVE: The overall objective of this systematic review is to synthesize the available evidence on the relationship between new knowledge (gained through educational interventions about substance use/abuse) and health care providers' attitudes (measured by well validated instruments such as the Drug and Drug Problems Perceptions Questionnaire [DDPPQ], the Short Alcohol and Alcohol Problems Perception Questionnaire [SAAPPQ], etc.) towards patients with substance-related presentations to emergency departments.The specific review question is: Among emergency department staff, does the acquisition of knowledge (on educational interventions about substance use) impact attitudes in relation to their therapeutic role towards patients with substance-related presentations?

BACKGROUND: Substance-related emergency department (ED) visits are common worldwide. Estimates of cases with alcohol involvement presenting to the ED range from 6% to 45%. Research conducted in the UK and Australia suggests that presentations related to illicit drug use are common and have increased in recent years.In 2012, an estimated six million Canadians met the criteria for substance use disorder; alcohol was the most common substance of abuse followed by cannabis and other drugs. The relationship between substance use and physical injury is well documented. The risk of mortality is increased by the side effects of substances on users involved in accidents and trauma. Not surprisingly, substance-related ED visits have been on the rise. Although only 3 to 10% of overall visits are typically related to a primary entrance complaint of drug or alcohol use or abuse, studies estimate that up to 35% of ED visits may be directly or indirectly substance related. These reasons may range from injury resulting from accidents or violence to substance-related illnesses.Health care providers (i.e., typically medical and nursing staff) have often perceived substance using patients as a challenging group to manage and as adding to the workload of already busy staff. The challenges of providing care to this patient population may be attributed to: (1) the chaotic ED environment, (2) health care providers' lack of knowledge, experience or skill in identifying and addressing substance misuse, (3) health care providers' lack of support structures such as sufficient time, staff and resources in working with this population, (4) health care providers' negative attitudes towards this patient population, (5) unpleasant tasks (i.e. intoxicated patients who urinate on themselves) associated with care delivery to this patient population, (6) patients' aggressive or violent behavior, and (7) patients' lack of motivation to change.Health care providers' attitudes towards patients with substance use problems have been found to affect health care delivery. This is of concern given the research findings that suggest they generally hold negative attitudes towards this patient population. For instance, in their study of nurses' attitudes towards patients who use illicit drugs, Ford, Bammer and Becker found that only 15% of nurses gained satisfaction from caring for these patients and only 30% were motivated to care for this patient group. Researchers who have examined substance using patients' experiences accessing health care also point to the suboptimal attitudes of health care providers towards this patient population. In the Neale, Tompkins and Sheard study of the barriers encountered by injecting drug users when accessing health and social care services, injecting drug users reported that they were often treated poorly or differently from other patients (i.e. sent home prematurely, not given appropriate aftercare or discharge), and made them feel not worthy of receiving help. Although the evidence relating to health care providers' attitudes toward substance using patients comes primarily from studies conducted in mental health or primary care settings, researchers who have examined ED staff attitudes towards this patient population paint a similar picture. For instance, Camilli & Martin's review of ED nurses' attitudes toward intoxicated and psychiatric patients suggests that nurses are often frustrated when it comes to these patients as they are time consuming and offer repeat business to the ED. An ethnographic study of care delivery in an ED also points to the negative attitudes of ED staff towards this patient group. Henderson, Stacey and Dohan found that ED providers had interactions with substance using patients that may be considered excluding, rejecting or de-valuing, that is, in observations and interviews, providers often spoke of this patient population as abusing the system, overusing system resources, and not caring about their own health care. Other negative attitudes of ED staff towards substance using patients found in the literature pertain to: (1) being reluctant to ask patients about substance use, (2) believing little can be done in EDs to help these patients, (2) feeling angry or professionally dissatisfied when treating this patient group, (4) lacking a sense of responsibility for referring to specialist treatment, and (5) believing patients lack motivation to change following interaction with medical staff.Although there is considerable evidence that indicates health care providers hold negative attitudes towards substance using patients, there are also some studies that have found positive attitudes towards this patient population. For instance, in their study of physician attitudes toward injecting drug users, Ding et al. found that seeing more injecting drug users was associated with more positive attitudes towards this patient population. Similarly, Kelleher & Cotter's descriptive study of ED doctors' and nurses' knowledge and attitudes concerning substance use found that the ED doctors and nurses who participated in the study had positive attitudes with regards to working with substance using patients. In the majority of these studies, however, positive attitudes were reported when health care providers were professionals working in addiction services, had more experience caring for this patient population, or had more personal contact with substance using patients. But does knowledge about substance use impact attitudes towards patients with substance-related presentations?Providing education or experience-based exercises may impact positively on attitudes towards substance using patients. Brief educational interventions, typically, informational sessions, either didactic or online, about alcohol and other drugs and how to assess and work with individuals using them, have been shown to have a positive impact on students' attitudes, knowledge and confidence relating to substance use and substance users. Whether ED staff attitudes towards patients with substance-related presentations are similarly impacted by the knowledge acquired through educational interventions remains unknown. A full systematic review of the literature will answer this question. A systematic review that examines the impact of knowledge on attitudes of ED staff will inform the design of educational strategies with emergency department staff to improve attitudes towards this patient population.To confirm that no other systematic review has been published on this topic, a preliminary literature search was conducted. The following databases were searched and no current or planned review was found related to this topic: JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, CINAHL, PubMed, and Scopus. Grey literature was also searched; however, no systematic review addressing the impact of knowledge on attitudes of ED staff towards patients with substance-related presentations was located.