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6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION “Substance abuse is a symptom. A lot of times there is something going on with a relationship and individual. People who feel unloved are going to use drugs to soothe those hurt places.” - Andrea Cohen June 26 is celebrated as international day against drug abuse and illicit trafficking every year. It is the third largest business in the world next to petroleum and arms trade with a turnover of around $ 500 billions. About 190 million people all over the world consume one drug or the other. Drug addiction causes immense human distress and the illegal production and distribution of drugs have spawned crime and violence worldwide. 1 Drug abuse is a complex phenomenon which has various cultural, biological, geographical, historical and economic aspects. The disintegration of the old joint family system absence of parental love and care in modern families where both parents are working, decline of old religious and moral values lead to a rise in the number of drug addicts who take drugs to escape hard realities of life. 1 In India the numbers of drug addicts are increasing day by day.Cannabis, heroin and Indian–produced pharmaceutical drugs are the most frequently abused drugs in India. Cannabis products often called charas, bhang or ganga are abused throught the country because it has attained some amount of religious sanctity because of its association with some Hindu deities. 1 In India there are 62.5 million users of alcohol, 8.7 million users of cannabis, and 2 million users of opiates such as heroin. A National survey released in 2004 revealed that 8% of drugs abusers are women. Often under the influence of drugs, addicts also indulge in high-risk behaviors such as unsafe sex and needle sharing which has contributed to the spread of infectious diseases such as HIV/AIDS and hepatitis C. 2 Alcohol and cocaine are very popular because they produce effects on the brain within minutes after consumption. The majority of drug users are aged between 16 to 30 years. These drug users are mostly unmarried, and from the lower socioeconomic strata, 33% of them are engaged in antisocial activities. Drug abuse causes a range of health complications from weakness, loss of body weight and respiratory distress. One of the most important effects of drug abuse is impaired judgement and a lack of rational thinking. Addicts develop psychological problems such as depression, anxiety and irritability. The incidence of drug abuse is also high among people with untreated psychiatric or emotional problems who often report taking drugs. 1 Thousands of drugs in nature and the many thousands of drugs have made in laboratories, but only a relative handful is used regularly for their effects on our mood, thinking or behaviour. The most commonly used drugs in the world are caffeine (found in tea, coffee and certain soft drinks), nicotine (in tobacco), and alcohol. These drugs are legal in most countries; other categories of drugs such as the opioids commonly used to treat pain, are either restricted to medical use or prohibited entirely. The effects of drug on brain and behaviour are different from one another. World Health Organization classify the drug in to the following categories, alcohol, opioids (opium and its derivatives, including heroin and morphine), cannoboinoids (such as marijuana), sedatives or hypnotics, cocaine, other stimulants including caffeine, hallucinogens, tobacco(nicotine), volatile solvents (inhalants). 3 Substance abuse among nurses has existed for at least 150 years. Historical research condcted by church (1984) showed that intoxication on the job existed even during mid-19th century when Florence Nightingale began her work. The problem of nurses with substance-related disorders gained increased awareness in the 1980s when the American Nurses Association (ANA) first addressed the issue. The ANA (1984) defined an impaired nurse as one who “has impaired functioning which results from alcohol or drug misuse and which interferes with professional judgement and the delivery of safe, high quality care.” The ability to identify nurses who have early manifestations of impairment could lead to an increased understanding of when to intervene through counseling and education.4 6.1 NEED FOR THE STUDY Nurses makes largest group in hospital, and they will have direct communication with patients. Nurses should have necessary knowledge about causes of addiction to drugs and its adverse effects because a nurse has to identify drug abusers and educate them regarding ill effects of substance abuse. 1 Knowledge is an important aspect. There is a need for knowing more about substance abusers and substance abuse syndrome in planning training programme for practising nursing personnel. Attitude play vital role in aspects of human life. Negative attitude interfere with action and proper understanding of these attitudes are necessary. Nurses may be suggested ways by which they may be helped to change or modify their attitudes. Drugs may be easily available to nurses by prescription (e.g. tranquilizers) and over-the-counter medications (e.g. analgesics). Nurses may abuse the drugs for relaxation and to induce sleep during stressfull working condition. Drug abuse among nurses causes impairment in their work and which will affect on patient. Substance abuse is viewed differently depending on the substance used, the person using it and the condition in which it is used, so nurses should be aware of these social and cultural attitudes and recognize their impact on individual users and people close to them. 1 A study conducted on prevalence of substance abuse among nurses revealed that 10% to 20% of nurses have substance abuse problems, and that 6%to 8% of registered nurses are impaired due to their abuse of alcohol and other drugs. Chemical dependency is considered a disease of that requires treatment. Early identification and treatment of chemically dependant nurse is important for the safety of the public and for the wellbeing of the nurse and her profession.5 Drug abuse has led to a detrimental impact on the society. It has led to a increase in crime rate. Addicts resort to crime to pay for their drugs. Drugs remove inhibitions and impair judgement influencing one on to commit affences. Incidence of eve-teasing, group clashes assult and impulsive murders increase with drug abuse. Apart from affecting the financial stability addiction increases conflicts and causes untold emotional pain for every member of the family. With most drug users being in the productive age group of 18-35 years, the loss in terms of human potential is incalculable. 1 Nurses have very important role in management and prevention of drug abuse. Nurses who are working in various areas such as school health nurse, community health nurse, mental health nurse and nurses in general hospitals has to give individual therapy and family therapy to prevent occurrence and relapse of drug abuse. 6 The effects of a chemically impaired nurse on staff could cause increased workloads, unit tension, decreased morale, guilt, anger, and a sense of betrayal or even denying advice. Substance abuse among nurses could be caused by many issues, from chaotic family situations to workload stress to past emotional traumas. Physical abuse, emotional abuse and sexual abuse often lead to lowered self esteem, isolation and impaired social skills, which are indicators of substance abuse. 1 In order to help a client to recover from substance abuse syndrome a nurse should show a spirit of acceptance and friendliness. A substance abuse patient is often not accepted in the society because the substance abuse has negative value in the society. If nurses do have negative attitudes toward drug dependent clients it may interfere with establishing a healthy and therapeutic relationship between the client and the nurse. By knowing the attitude of nursing personnel they can be helped to overcome their negative attitudes. 6.2 REVIEW OF LITERATURE Review of literature is a systematic identification, location, scrutiny and summary of written materials that contain information on research problems (POLIT. D. F. and B.P. HUNGLER). The researcher presents the review of literature which helps to study the problem in depth. It also serves as a valuable guide to understand what has been done and what is still unknown and untested. A study conducted tests on emergency room nurses regarding their knowledge and beliefs about substance misusers. Study reveals that emergency room nurses regard alcohol and drug misusers as troublesome patients and dislike caring for them. Programmes designed to change nurses attitudes towards substance misusers are generally ineffective, although significant gains in substance-related knowledge are commonly reported.7 A questionnaire on nurses knowledge, attitudes, beliefs and practices regarding substance use was distributed to 302 nurses in Victoria, Melbourne. 134 returned the questionnaire, giving an overall response rate of 44.3%. The survey results showed that although knowledge and skill gaps exist in assessment and management of alcohol and drug problems, overall knowledge levels were adequate. Although positive attitudes towards substance use were expressed, specific educational programs to enhance nurses skills in assessment and management of substance-related disorders may be useful.8 A study conducted to assess nurses knowledge and attitude regarding substance use and substance users. It was done on emergency room nurses because they are frequently exposed to patients with substance use problems and are in ideal positions to provide early diagnosis and treatment. The result showed that only 25-50% of nurses had the knowledge to detect patients with substance abuse.9 A study to assess nurses activity in screening substance abuse among their patients. Here nurses of department of surgery were asked to predict if the surgical patients treated during 24-h period (n=211) had a substance abuse disorder. This was compared to patients self-reports based on the Alcohol Use disorders Identification Test (AUDIT) and questions about use of other substances. The nurses were also asked to complete a questionnaire related to interventions of patients with substance abuse; perceived knowledge, skills, attitudes and obstacles. Result showed that only 18% of nurses reported enough knowledge to conduct intervention.10 An interview study examined the attitudes of healthcare professionals towards drug misuse and misusers. They represented a sub-sample of a larger study of 248 professionals working with intravenous drug missusers in West Scotland. It was thought that nurses attitudes could affect their emotional responses and the subsequent care they gave to patients. The results suggested that staff have judgmental and punitive attitudes to drug abusers. Most respondents felt that drugs corrupt the young and that drug misusers should only cared in specialized units.11 A study done a survey of qualified Greek nurses, comparing smoking attitudes, influences on smoking behaviours and desire to quit with their motivation to act as health promoters with patients and other health professionals who smoke. A random sample (n=402) of qualified nurses employed by hospitals in Athens was surveyed with a self administered questionnaire in a cross- sectional survey which had a 73% response rate. Following quality control measures, a final sample of 308 was achieved. Results showed that almost half of the nurses in the sample were current smokers, almost a quarter were former smoker, with just a less than a third non-smoker. Using the stages of change model as a measure, the survey reported that 11% of the smokers in the sample expressed a desire to stop within the next month; another 12% in the coming 6 months and 23% of current smokers were still in the pre-contemplation stage. 12 A study conducted on 50 nurses to assess the prevalence of substance abuse in Rajendra hospital and medical college Patiala by means of a structured self report questionnaire. The life time prevalence of drug abuse among nurses was 55%, majority of nurses were taking tranquilizers and sedatives for relaxation and inducing sleep.13 A study found that about 32% of the 4,438 nurses surveyed reported drinking, smoking or using drugs. While nurses’ use of drugs and alcohol is about the same as the general population, the study found that critical-care and emergency department nurses are more than three times as likely to abuse narcotics as nurses in other specialties.14 A study assessed the prevalence of licit (e.g. alcohol) and illicit (e.g. cocaine) drug use as well as prescription (ex: tranquilizer) and over-the-counter medications (e.g. analgesics) in regional sample of female nurses. Surveys were mailed to a random sample of 4000 nurses in Western New York. The survey focused on life time and current use of substances, negative consequences of alcohol consumption and dependence. Three mailings resulted in return of 2400 (60%) surveys, of which 1951(49%) nurses were abusing drugs.15 A study conducted on prevalence of substance abuse among 907 registered nurses selected through stratified random sampling technique. Study reveals that prevalence of substance use as follows, alcohol drinking (regular use-3.8%), Cigarette smoking (regular use 0.2%), analgesics (regular use 21.1%), benzodiazepines (regular use 1.8%) and use of narcotics (ever use 0.7%).16 A Study reveals that the prevalence of substance abuse in the nurses is parallal to that in the general population (that is approximately 10%). Nurses with substance abuse problem need help. They are in danger of harming patients, the facility’s reputation, the nursing profession and themselves. The consequences of not reporting substance abuse can be far worse than those of reporting the issue.17 10-15% of all health care professionals misusing drugs at some time in their careers. Drug abuse by health care professionals may also be more difficult to detect than among the general population. Those in health care will alienate their families, destroy their finances, dropout of their usual recreation and only then have their problems show up on their job.18 A study conducted a cross sectional surveys among 110 male medical school faculty (MSF), 229 physicians (67% male), 1130 medical students (46% male), and 73 female nursing students. Information on tobacco use and quit attempts was collected using structured questionnaires. Among the male respondents, current smokers were 15% of male medical school faculty, 13% of physicians, and 14% of medical students.19 6.3 STATEMENT OF THE PROBLEM A study to “assess the knowledge and attitude regarding substance abuse among nurses in selected hospital, Tumkur” 6.4 OBJECTIVES To assess the existing knowledge towards substance abuse among nurses. To assess the existing attitude towards substance abuse among nurses. To determine the association between knowledge and attitude towards substance abuse among nurses. To determine the association between knowledge and attitude regarding substance abuse among nurses with demographic variables such as age, sex, education, experience etc 6.5 HYPOTHESIS H1 There will be significant relation between knowledge and attitude regarding substance abuse among nurses. H2 There will be significant association between knowledge and attitude in selected demographical variables such as age, sex, religion, education, experience, marriage and family type . 6.6 OPERATIONAL DEFINITIONS Knowledge It refers to the information and facts obtained from nurses on the aspects such as causes, effects, treatment regarding selected substances. Attitude A degree of positive or negative effect associated with substance abuse among nurses. Substance abuse The misuse of drugs and alcohol which will produce a negative impact on health and behavior. Nurses Nurses who are working in selected hospital Tumkur. Selected Substances The commonly used substances such as nicotine, alcohol, lysergic acid, diethylamide, cocaine, Amphetamine, Opiate and opiods. 7. ASSUMPTION Substance abuse is a one among the problem in the society. If it remains unaware about knowledge on substance abuse among nurses it will lead to improper patient care. So by assessing the knowledge of nurses about substance abuse helps to increase their knowledge level and make them aware of ill effects of substance abuse and its management. 7.1 MATERIALS AND METHODS 7.1.1 SOURCES OF DATA 7.1.2 Research Approach : Descriptive survey 7.1.3 Research Design : Non experimental research design 7.1.4 Settings of the study : The study will be conducted 0n nurses in selected hospital Tumkur. 7.1.5 Sample size : 75 7.1.6 Sampling Technique : Simple random sampling technique. 7.1.7 Selected variables:Independent Demographic variables ex: age, sex, education, experience, monthly income etc. Dependent Nurses knowledge on substance abuse. 7.1.8 Sample criteria Inclusion criteria: - The study includes nurses Who are available during data collection. Who understand Kannada or English or Hindi. Who are willing to participate in the study. Exclusion criteria: - The study will not include Nurses who are not available during data collection. Nurses who are not able to understand Kannada or English or Hindi. Nurses who are not willing to participate in this study. 7.2 METHODS OF DATA COLLECTION 7.2.1 Data collection technique : Structured interview schedule 7.2.2 Tools for Data Collection : Structured Questionnaire 7.2.3 Methods of Data Analysis And Interpretation : Data will be analyzed according to the objectives of the study using descriptive and inferential statistics. 7.2.4 Duration of the study : 6 weeks. 7.3 Does the study require any investigations or interventions to be conducted on the patient or other human beings or animal? The study does not require any investigation and interview on patients and other human beings or animals 7.4 Has ethical clearance been obtained from you institution? Yes Ethical clearance has been obtained from Institutions Ethical Committee (IEC) and the consent. 8. LIST OF REFERENCES 1. 2. Substance abuse problems in India. http:// www.google.com. Donna K. MC Neese -Smith, Nirmala Gangadurai, Nirmala Thangavalu, et.al Nurse education of the public in India about the dangers of substance abuse 2006; Vol. 7 No1. 3. Floyd E Bloom M P et.al, The DANA guide to bright condition centre substance abuse and addiction March 2007 . 4. Margaret Mary. Journal of Nursing Scholarship. Early risk indicators of substance abuse among nurses June 2002. 5. Griffith J. substance abuse disorders in nurses. mjv 2v @ HSC mail. mcc.virginia.edu.1997. 6. T.P. Prema and K. F. Graicy, Principles and Practice of psychiatric nursing. 1st edition, 2006. 7. Howard M.O, Chung S.S, Substance use misuse: Nurses attitudes towards substance misusers Aug, 2000; 35(9): 1227-61. 8. Happel. B, Carta. B, Pinikahana. J, Nursing Health Science, Nurses knowledge attitudes and beliefs regarding substance use: a questionnaire. Dec 2002; (4), 193-200. 9. Kelleher S. Accident Emergency Nurses July 2007; 15(3): 161-5. 10. Lappalainen-Lehto R. Seppa. K. et. al. cutting down substance abuse: present state and visions among surgeons and nurses. Addictive behaviors 30(5): 1013-1018, 2005. 11. Carroll. J, Nursing standard, the negative attitude of some general nurses towards drug misusers. 9(34): 36-38, May 1995. 12. Beletsioti-Stica. R, Scriven. R. International Nursing Review. Smoking among Greek nurses and their readiness to quit. 53(2): 150-156, 2006. 13. Gurmeeth. Sing, Jindal. K.C, Drug alcohol depend. Drug on medical campus, drug use among nursing and paramedical personnel, 7(1), 31-37, Feb, 1981. 14. Alison Trinkoff and Carla Storr American Journal of Public Health. 1998. 15. Collins. R.L, Gollnisch. G, et. al,drug alcohol depend, 1;55, 145-55, June, 1999. 16. Yang M.S, Yang M. J, Pan S.M. Kaohsing Journal of medical science: Prevalence and correlates of substance use among clinical nurses in Kaohsiung, 17(5), 261-269, May 2001. 17. Dunn. D. Substance abuse among nurses. Defining the issue. AORN. J. 82(4): 572-596, 2005. 18. Nightingale Nursing times June 2005; page 03 and 57. 19. Mohan S, Pradeepkumar, et. al, Tobacco use among medical professionals in kerala, India : Addictive behaviors 2006; 31(12): 2313-2318.