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An exploration of the role of substance misuse nurses in Scotland

Chapter 2: Methods

Both qualitative and quantitative methods were used to gain an understanding of the role of the substance misuse nurse in the provision of drug misuse services in Scotland. The methods used consisted of three core components:

1. Questionnaire survey,

2. Semi-structured, in-depth, face-to-face interviews,

3. Observational fieldwork.

These are presented below.

Questionnaire survey

Identification of the population: scoping exercise

A scoping exercise was conducted in order to identify the substance misuse nurse population. The aim was to identify all substance misuse nurses directly involved in the care of drug misusers and working in statutory agencies. This will have included people who worked with drug and alcohol users but those that worked exclusively with alcohol users were excluded. Prison nurses were specifically excluded as they were considered to work in a very different service framework. All drug problem or substance misuse clinics in Scotland were identified by contacting Drug Development Officers and/or Drug Action Teams in each Health Board area across Scotland. Other agencies/services were identified on the Scottish Drug Forum and the Information and Statistics Division Drug Misuse websites. Non-statutory or voluntary agencies and each relevant agency/service were contacted by letter requesting names of all nurses working in the field of drug misuse. A database was set up and all names and addresses were listed. In total 272 substance misuse nurses were initially identified by the scoping exercise. Table 1 presents the number of services and substance misuse nurses identified in each NHS area.

Construction of the questionnaire

A questionnaire was developed informed by a literature review, previously used validated questionnaires in GPs (Matheson et al., 2003) and pharmacists (Matheson et al., 2002) and a previously conducted Grampian based pilot study (Graftham et al., 2004). The questionnaire covered attitudes to drug misusers and current treatment options (maintenance prescribing, detoxification and rehabilitation), beliefs about treatment effectiveness, and possible barriers to treatment, number of drug misusers on caseloads, the use of protocols/guidelines, services provided (prescribing support, monitoring, counselling, community detoxification etc), and perceptions of service development priorities.

The questionnaire was anonymous. For the purposes of identifying non-respondents, responders were asked to post an identifiable reply paid postcard at the same time as they returned their questionnaire, thus notifying the research team they had replied. The questionnaire was then piloted following minor adjustments, between November 2002 and March 2003, and mailed to all substance misuse nurses identified by the scoping exercise (Forth Valley in March 2004), n=272. Where appropriate, up to three reminders were sent. The questionnaire is shown in Appendix 1.

Questionnaires were distributed to 244/272 nurses: 28 nurses who had been identified in the scoping exercise were no longer employed at the respective service/agencies and were removed from the database.

Data management and analysis

Data from returned questionnaire were coded and entered into Statistical Package for the Social Sciences (SPSS, version 11.5). Open-ended questions were analysed to identify themes, and were also entered into SPSS. Frequencies, descriptive statistics and cross tabulations were undertaken including chi-squared tests where appropriate. All data were stored securely and confidentially, in line with the Data Protection Act (1998) and research governance guidance.

It was possible to compare some questionnaire data with data from similar questionnaire surveys conducted with pharmacists in 2000 (Matheson et al., 2002) and GPs in 2000 (Matheson et al., 2003). Simple comparisons of attitudes of nurses to drug misusers and service delivery are presented where relevant, in chapter 4. Similarly, comparison with GPs practice, beliefs about treatment and the organisation of services are presented at the end of chapter 6.

Semi-structured face-to-face interviews

Interviewee sampling

On the reply paid postcard referred to above, nurses were asked if they would be willing to take part in a face-to-face interview. In total, 79 nurses indicated that they would be willing to take part in a face-to-face interview. Using the agreed selection criteria i.e. number of years working with drug misusers, gender and geographical area, 38 nurses were selected. Of these, three nurses were signed off work long-term, five no longer worked for the service, one declined to take part (i.e. he was too busy) and one was on maternity leave. Therefore, 29 nurses, ten males and 19 females, were successfully interviewed (see table 2).

An interview schedule was informed by the previously conducted pilot study, issues identified in the literature, and discussion within the steering group. The primary focus of the interview schedule was on the nurse's assessment of patients seeking professional help with their drug misuse and the decision making process that followed. However, a section for demographic data was included. This was completed by the researcher at the start of each interview. The interview schedule was used in each interview to ensure consistency whilst allowing for in depth exploration of issues arising. The interview schedule was piloted with three nurses working with the Substance Misuse Service in Aberdeen in order to identify ambiguous or conflicting questions. Alterations were made as necessary. These primarily related to including views on stress and the specific issue of integrated drug services. The interview schedule can be found in Appendix 2.

Conducting interviews

Interviews were conducted with substance misuse nurses prior to a clinic. With the consent of nurses, all interviews were audio-taped and subsequently transcribed. Data were stored in a password-protected computer file and analysed by constant comparative analysis supported by Nudist software. Interviews were conducted between April and September 2003.

Observational fieldwork

Observational fieldwork was carried out during nurse consultations with drug misusers. The main purpose of observation was to give the interview context as well as to allow insight into: whether nurses take into account their clients' views when deciding on a treatment plan, the structure of the interview and the setting where consultation takes place. To reduce the influence of the researcher's perspective (Mason 1996) a data collection form was constructed to allow the researcher to record the content of the consultation. A copy of the observational checklist can be found in Appendix 3.

Recruitment of patients for observation

Two weeks prior to their consultation patients were sent information about the study. Clients were asked to inform their nurse if they were willing to allow a researcher to sit in on their consultation. Written consent was not requested until the day of the consultation. Both clients and nurses were informed that they were free to ask the researcher to withdraw from the consultation at any time.

Observation of consultations

The researcher observed either a half-day or full day of consultations. In total 15 patient consultations were observed. An overt non-participant role was assumed. Field notes were taken unless a request had been made by the nurse or patient for the researcher to leave. Observation notes were written up as soon as possible after leaving the scene and before speaking with the nurse. Additionally each nurse and patient was asked if they felt that the researcher's presence had influenced their behaviour in any way. All consultation observations were conducted between April and September 2003.

Ethical approval

Multi-Centred Research Ethics Committee (MREC) approval was granted in March 2003. Following this Local Research Ethics Committee (LREC) approval was obtained for the Health Boards where interviews and observation were planned.

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