Nurses substance use and resilience patterns

doi:10.21203/rs.3.rs-3235280/v1

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Nurses substance use and resilience patterns

https://doi.org/10.21203/rs.3.rs-3235280/v1

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Background and Aims: Some nurses may turn to non-adaptive behaviors including patterns of substance use during their daily pressured routines and in crisis times. This study aimed to assess nurses’ substance use and resilience patterns during the past three months.

Design and Analysis: Descriptive data was collected from nurses using convenient sampling from public, educational and private sector hospitals. Chi-square analysis was used to test the association between substance use and nurses’ gender and type of health care sector. Student t-test examined the impact of resilience level on substance use.

Setting: Amman-Jordan.

Participants: 1000 hospital based nurses.

Measurements: The outcome variable was substance use differentiated by category. Related variables such as gender, age, type of hospital and other socio-demographic variables were assessed by self-reported questionnaire. Resilience as an independent variable was measured by Connor-Davidson resilience Scale (10-items) (1).

Findings: The highest prevalence of substance use among nurses was found in caffeinated drinks followed by smoking then hypnotics and the lowest prevalence was for cocaine. Significant associations were found between substance use and gender in favor of males in smoking ( p< .001), alcohol use, cannabis and hypnotics. Significant association was found between nurses in private hospitals and substance use over their partners in educational and public hospitals, in favor of alcohol, cannabis, cocaine, stimulants, inhaled substances, hypnotics, hallucinating agents and opioids. Significant differences in resilience score between users and none-users were found in alcohol, cannabis, cocaine, stimulants, hypnotics, hallucinating agents and opioids. Non-users scored higher in resilience mean scores for all substance types.

Conclusions: Traumatic psychological experiences, work and life pressures induce some protective mechanisms to help nurses endure emotional pain. Some of those mechanisms include patterns of smoking, alcohol and other forms of substance use. Remarkably, nurses who use substances show less resilient patterns.

nurses

substance use

resilience

Nurses are every day’s health care providers and their care burdens were high and got peaked during the latent COVID-19 (2). Examples of confronted burdens during the pandemic included inadequate preparedness, emotional challenges, insufficient supplies and lack of crucial evidences in regard to treatment plans (3). Some burdens were related to work environment while others were psychosocial in nature (4).

It was evident that the peri-COVID-19 nurses’ work and life stressors, gave birth to negative psychological consequences which involved anxiety, fear, grief, helplessness, anger, emotional distress, spiritual distress, depression, compassion fatigue, suffering and burn out (5, 6). Those traumatic feelings induced some protective mechanisms to help nurses endure the associated emotional pain. Some mechanisms were adaptive; for example seeking emotional support, talking to a friend or a relative, playing sport, positive self-talk and seeking professional help (7, 8). Yet, there were some maladaptive coping resorts which involved oversleeping, TV addiction, mobile addiction, game addiction and starting to use or increase the frequency of use of some substances (6, 9, 10).

Substance is defined as “ any psychoactive compound with the potential to cause health and social problems, including addiction”(11). Some substances may be legal (e.g., tobacco, coffee, power drinks, alcohol and prescribed controlled drugs used for medical purposes (e.g., hypnotics, antianxiety drugs, sedatives and antidepressants); while others are illegal (e.g., cannabinoids: marijuana, hashish,..), opioids (Heroin, morphine, pethidine,..), stimulants (amphetamine, methamphetamine,..), cocaine, inhaled substances (paint thinners, glue,..) and hallucinogens (LSD, mushroom, Ecstasy,..) (12). Nurses use of substances comes with negative consequences on nurses, their families, the community and the safety and quality of care provided for patients (13). In support of this, the American Nurses Association (ANA) estimated that 6–8% of nurses have a drug or alcohol problem that impairs their practice (14).

Recent evidence suggests that general population patterns of smoking, alcohol and substance use have trended towards an increase during COVID-19 (15). While nurses’ drug use findings in the USA in the past year showed that illicit drug use was 5.7%, and prescription-type drug misuse was 9.9%. Energy drink use was reported by 23.7% of nurses younger than 45 years and 18% of nurses screened positive for substance use problems. Staff, charge nurses, nurse managers had 9 to 12 times the odds of having a substance use disorder as opposed to educators and researchers (16). Such numerical inferences reinforce the necessity to track nurses substance use indicators on a systematic basis.

Many theorists tried to explain the substance use behavior. The resilience model is one interesting framework that help view the substance use behavior in a rational sense (10). It simply assumes that resilient people will not seek less adaptive ways to solve their problems and face emotional trauma (17, 18). On the contrary; those who are less resilient may resort to less adaptive techniques to manage their stressors (19, 20). Such techniques include forms of substance use that extend to misuse or addiction (21).

Navigating through nurses’ substance use maps and their interactions with the twinned resilience patterns generates worthy sets of data that help interpret the phenomenon, capture the roots of the problem, and actively build psycho-social rehabilitation and support programs that mitigate the negative consequences, heal the emotional wounds, lend a hand to those who are in desperate need for help, and provide alternatives for coping with the psychological trauma. Such alternatives for substance use are less costly to personal lives, professional identities and health care systems.

Study Sample

Convenient sampling ended with a total of 1000 hospital based nurses who worked at bedside level with COVID-19 clients for at least six months during the first four peaks in Jordan. It is necessary to point out that the third pandemic wave had approximately peaked on (21, November, 2021) and the fourth wave had peaked on (18, February,2022) (22). Our study data collection time extended from October, 2021 to July, 2022 and the attrition rate was 16.67%. Data was collected from nurses who agreed to participate and signed the consent form.

The surveys were distributed by trained researcher assistants in major clinical settings located in Amman, the capital of Jordan. The included clinical settings were a major academic hospital, three large private hospitals and two central public hospitals.

Measures

The consenting participants were asked to fill a survey which was structured into three sections. Section one included demographic variables of health sector, unit, age, gender, experience in nursing, academic degree and marital status (Table 1).

Table 1

Sample Characteristics (N = 1000).
Variable	N (%)
Sector
Governmental	600 (60)
Private	150 (15)
Educational	250 (25)
Gender
Male	457 (45.7)
Female	543 (54.3)
Educational level
Diploma	142 (14.2)
Bachelor	794 (79.4)
Higher education	64 (6.4)
Marital status
Married	635 (63.5)
Single	311 (31.1)
Separated	54 (5.4)

Section two was a table ( supplementary 1) derived from the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) which was developed by the World Health Organization (WHO) in 2010. ASSIST is a scale rated (0,2,3,4,6) which describes the substance use frequency within the past three months. Zero means no use, 2 means once or twice within the past three months, 3 means monthly use that is 1 to 3 times every month for the past three months, 4 means weekly use that is 1 to 4 times per week for the past three months, and 6 means daily or almost daily use for the past three months (23). Consent to use the substance types’ table was granted from WHO.

In the analysis part, we turned the substance use frequency answers into a “ No, yes”. “No” for nurses who didn’t take the mentioned substance, and “yes” for those who took it in the past three months regardless of the frequency. The scientific rational was to allow the use of Chi-square test to detect the association between substance use and nurses’ gender and type of health care sector and the use of student’s t-test to detect the association between resilience and substance use. Though all the “frequency tables of examined substances” were maintained for future possible comparisons and provided as supplementary materials (supplementary 2–11).

The Categorized substances in the ASSIST derived table (supplementary 1) were smoking (all types), alcohol, cannabinoids (Marijuana, hashish, Joker, Flaka..), cocaine, stimulants (Captagon (a highly addictive amphetamine), speed (methamphetamine), ecstasy (3,4-methylenedioxy-methamphetamine (MDMA)), crystal myth/ice (crystal methamphetamine)..), Inhalants (paint thinners, glue, lighter fluid,..), hypnotics/sedatives ( lexopam, diazepam, alprazolam, midazolam, lorazepam, clonazepam,..), Hallucinogens ( ketamine, mushroom, trip (psychedelic drugs), LSD (Lysergic acid diethylamide) ,..), Opioids ( Heroin, pethidine, fentanyl, propofol, methadone, morphine, codeine, ..), and the 10th category of substances contained caffeinated beverages e.g.,. coffee, power drinks and similar products (23).

Section three in the handed survey was a resilience score measured by The Arabic validated version of Connor-Davidson resilience Scale (CD-RISC10) ( supplementary 12). The CD-RISC 10 is a one-dimensional self-reported scale consisting of 10-items measuring resilience. Respondents rate items on a 5-point Likert scale, ranging from 0 (not true at all) to 4 (true nearly all the time). Each item has a minimum score of 0 and a maximum score of 4. Total scores for the CD-RISC 10 range from a minimum of zero to a maximum of 40. Total scores are calculated by summing all 10 items. A higher score indicates higher resilience. None of the items were reverse scored. The Arabic version of CD-RISC10 instrument is valid and reliable Consent to use the CD-RISC10 scale was granted. Nevertheless, CD-RISC10 is controlled version and shouldn’t be used except after direct permission of its intellectual right owners with strict citation requirements (1).

Analysis

Data was entered into SPSS program version 21, cleaned and screened for errors and missing data. Descriptive statistics of frequencies, percentages, means and standard deviations were used to describe the study variables. Chi-square test was applied to examine the association between substance use and nurses’ gender and type of health care sector. Students’ t-test was applied to examine the impact of resilience level on nurses’ reported substance use.

Sample Characteristics A total of 1000 nurses participated in this study in which 54.3% were females, 60% were from governmental hospitals, 79.4% had bachelor’s degree in nursing, 63.5% married, and age range was between (20–58) years (Table 1).

Percentage of Substance Use Among Nurses The highest percentage of substance use among nurses was for caffeinated drinks (71.8%) followed by smoking (48.4%) and hypnotics/sedatives (16.7%). The lowest percentage of substance use was for cocaine (6.1%) (Table 2). Associations Between Nurses Gender and Substance Use Significant associations were found between substance use and gender in the favor of males in smoking (X² (1) = 76.4, p < .001) (63.5% male; 35.7% female), alcohol use (X² (1) = 9.62, p = .002) (11.6% males; 6.1% females), cannabinoids (X² (1) = 5.58, p = .018) (9.2% males; 5.3% females) and hypnotic use (X² (1) = 14.9, p < .001) (21.7% males; 12.5% females) (Table 3).

Table 2
Percentage of Substance Use Among Nurses (N = 1000).
Substance group	No	Yes
Smoking	516 (51.6%)	484 (48.4%)
Alcohol	914 (91.4%)	86 (8.6%)
Cannabis	929 (92.9%)	71 (7.1%)
Cocaine	939 (93.9%)	61 (6.1%)
Stimulants	927 (92.7%)	73 (7.3%)
Inhaled substances	924 (92.4%)	76 (7.6%)
Hypnotics /sedatives	833 (83.3%)	167 (16.7%)
Hallucinogens	930 (93)	70 (7%)
Opioids	920 (92%)	80 (8%)
Caffeinated beverages	282 (28.2%)	718 (71.8%)

Table 3
Associations Between Nurses Gender and Substance Use ( N = 1000).
Substance group	Male	Female	Chi-square	P value
Smoking	290 (63.5%)	194 (35.7%)	76.40	.000***
Alcohol	53 (11.6)	33 (6.1)	9.62	.002**
Cannabis	42 (9.2)	29 (5.3))	5.58	.018*
Cocaine	34 (7.4)	27 (5)	2.64	.10
Stimulants	38 (8.3)	35 (6.4)	1.28	.26
Inhaled Substances	39 (8.5)	76 (7.6)	1.05	.31
Hypnotics /sedatives	99 (21.7)	68 (12.5)	14.90	.000***
Hallucinogens	39 (8.5)	31 (5.7)	3.04	.08
Opioids	44 (9.6)	36 (6.6)	3.03	.08
Caffeinated beverages	338 (74)	380 (70)	1.94	.16
test is significant at .05 (tow tailed). test is significant at .01(tow tailed). ** test is significant at .001(tow tailed).

Associations Between Nurses’ Health Sectors and Substance Use Significant association was found between nurses who work in private hospitals and substance use as follows: alcohol (X² (1) = 29.19, p < .001) (20% private, 6.7% public, and 6.4% educational), cannabis (X² (1) = 32.15, p < .001) (18% private, 6% educational, 4.8% public), cocaine (X² (1) = 36.48, p < .001) (16.7% private, 5% public, 2.4% educational), stimulants (X² (1) = 27.18, p < .001) (18% private, 6.3% public, and 3.2% educational), inhaled substances (X² (1) = 33.79, p < .001) (18.7% private, 6.7% public, and 3.2% educational), hypnotics (X² (1) = 6.86, p = .03) (24% private, 15.7% public, and 14.8% educational), hallucinating agents (X² (1) = 33.96, p < .001) (18% private, 5.7% public, and 3.6% educational), and Opioids (X² (1) = 33.57, p < .001) (19.3% private, 7% public, and 3.6% educational) (Table 4).

Table 4
Associations Between Health Care Sectors and Substance Use (N = 1000).
Substance group	Public	Private	Educational	Chi-square	P value
Smoking	300 (50)	75 (50)	109 (43.6)	3.08	.22
Alcohol	40 (6.7)	30 (20)	16 (6.4)	29.19	.000***
Cannabis	29 (4.8)	27 (18)	15 (6)	32.15	.000***
Cocaine	30 (5)	25 (16.7)	6 (2.4)	36.48	.000***
Stimulants	38 (6.3)	27 (18)	8 (3.2)	27.18	.000***
Inhaled substances	40 (6.7)	28 (18.7)	8 (3.2)	33.79	.000***
Hypnotics/sedatives	94 (15.7)	36 (24)	37 (14.8)	6.86	.03*
Hallucinogens	34 (5.7)	27 (18)	9 (3.6)	33.96	.000***
Opioids	42 (7)	29 (19.3)	9 (3.6)	33.57	.000***
Caffeinated beverages	426 (71)	112 (74.7)	180 (72)	.80	.67
test is significant at .05 (tow tailed). ** test is significant at .001(tow tailed).

Table 5
Differences in Resilience between Substance Users and Non-Users
Substance group	No	Yes	T value	P value
Smoking	23.4 (8.4)	23.4 (8.1)	.185	.85
Alcohol	23.6 (8.3)	21.5 (7.3)	2.27	.023*
Cannabis	23.6 (8.3)	20.9 (7.5)	2.65	.008**
Cocaine	23.6 (8.2)	20.5 (7.7)	2.82	.005**
Stimulants	23.6 (8.2)	20.6 (7.8)	2.98	.003**
Inhaled substances	23.5 (8.2)	21.8 (8.4)	1.81	.07
Hypnotics/sedatives	23.8 (8.4)	21.6 (6.9)	3.51	.001**
Hallucinogens	23.6 (8.2)	20.9 (8.2)	2.69	.007**
Opioids	23.6 (8.3)	21.3 (7.8)	2.36	.019*
Caffeinated beverages	23.7 (9.3)	23.3 (7.8)	.622	.53
test is significant at .05 (tow tailed). *test is significant at .01(tow tailed).

Differences in Nurses’ Resilience between Substance Users and Non-users Significant differences in nurses’ resilience scores between users and none-users of substances were found in alcohol (t (998) = 2.27, p = .023), cannabis (t (998) = 2.65, p = .008), cocaine (t (998) = 2.82, p = .005), stimulants (t (998) = 2.98, p = .003), hypnotics (t (998) = 3.51, p = .001), hallucinating agents (hallucinogens) (t (998) = 2.69, p = .007) and opioids (t (998) = 2.36, p = .019). As shown in Table 5 the non-users scored higher in resilience mean scores for all substance types than substance users.

Discussion Percentage of Substance Use Among Nurses Anti-Narcotics Department stated that there had been a “notable increase” in drug-related cases in the Kingdom. Besides, The Public Security Directorate reported that a total of 6,196 people had been caught in drug abuse and drug dealing cases in the past year (24). The authorities in Jordan stick to the official story that Jordan is a “ Transit” which means a passing point for drugs, not a spot for flourished drug trafficking (25). Drug dealers smuggle drugs across Jordan to its final destinations in Egypt and the Gulf countries. Different types of drugs are being transited through the Gulf of Aqaba and the border with Syria, where Jordanian authorities seized, for example, 47 million Captagon ( amphetamine based drug ) pills in 2018 (26). Those facts rise serious concerns about substance use in Jordan in general. Nurses constitute one portion of the Jordanian population. They share the same daily concerns and socio-economic pressures, in addition to the complex nature of their job that includes a wide range of stressors and a heavy legacy of COVID-19 which came with tremendous burdens and exaggerated costs on the nursing professional body (27). In response, some nurses turned or turned more to smoking behavior as a coping mechanism (6, 7, 10). Our study showed an average nurses’ smoking rate of 49.6% ( 63.5% in males, 35.7% in females). In comparison, Jordan’s smoking rate in 2020 was 34.8% ( averaged for both sexes) (28). An increasing prevalence of smoking in Jordan had been noted earlier in 2014 in a study that included a sample of 3196 adults with an overall 32.3% ( averaged for both sexes) of the respondents reported being current smokers (54.9% in adult males and 8.3% in adult females). That same study recommended that reducing the rate of smoking in Jordan must be a strategic national priority (29). Our study results confirmed that smoking rates are among the highest in the world, they were high among nurses especially during COVID-19, they were higher than the rates of the general population for both sexes, and the smoking balance still in favor of male nurses over their female partners.

Alcohol is a psychoactive central nervous system depressant substance with dependence-producing properties. Its harmful use causes a high disease burden and has significant degrading social and economic consequences (30). Alcohol consumption causes death and disability relatively early in life. For instance, in people aged (20–39) years, approximately 13.5% of total deaths are attributable to alcohol (31). Jordan is an Arab country, with a majority of Muslims, where alcohol consumption is prohibited by religion (32). Though, there are some followers of other religions and some visiting tourists whose religious beliefs allow drinking alcohol in moderation (33). In spite of the moral ideals; we can admit that some Islam followers drink alcohol, discretely and sometimes; in excess (34).

In nurses, a study published in 2018 found that 23 out of 282 (8%) nurses reported alcohol use (10). In comparison, our study ended with 86/1000 (8.6%) nurses reporting alcohol use during COVID-19. A qualitative study of 42 Australian nurses concluded that several participants disclosed their increased alcohol consumption during COVID-19, particularly due to the stressful work environment. Workplace factors such as overtime, scarce resources, missed breaks and heightened workload, were all described as driving stressors for alcohol consumption (35). Remarkably, a Californian thesis explored the incidence of substance use among nurses prior to the pandemic versus today and said that alcohol was the most prevailing substance used by nurses during the pandemic, followed by tobacco and marijuana (36).

Finally, we looked at nurses’ use rates of other forms of substances. For example, a Michigan survey of 615 nurses reported an increase in substance use in general (32%) and (2.6%) reported an increase in marijuana use (37). Besides, the prevalence estimates of the “Nurse Work life and Wellness Study” reported that the year 2021 witnessed nurses illicit drug use ( e.g., cocaine, hallucinogens, marijuana, synthetic cannabinoids, methamphetamines, opioids, …) of (5.7%), prescription-type drug misuse was (9.9%), energy drink use was (23.7%) in nurses younger than 45 years, (18%) of nurses screened positive for substance use problems, with one-third of those screening positive for substance use disorder (38). In Jordan, the percentage of illicit drug use scored the least in cocaine (6.1%), then hallucinating agents (7%), cannabis (7.1%), stimulants (7.3%), inhaled substances (inhalants) (7.6%), and the highest score was for opioids (8%). So, it could be concluded that nurses in Jordan exceeded the substance use rates when compared to their partners in the “Wellness Study”. Similar findings were noted in regard to prescribed drugs like hypnotics, etc.; caffeinated beverages and power drinks.

Associations Between Nurses Gender and Substance Use

Junqueira et al (2018) confirmed that female nurses presented low odds ratio of alcohol beverage binge consumption (56% or OR 0,44 [IC95% 0,26 − 0,77]; p = 0,003) and of using marijuana in medium/high risk level in comparison with male nurses (81% - OR 0,19 [IC95% 0,05 − 0,77]; p = 0,020) (39). Significantly matching our findings of association found between substance use and gender in favor of males in smoking ( p < .001), alcohol use, cannabis and hypnotics. Many studies were supportive of this finding (40).

Associations Between Nurses’ Health Sectors and Substance Use

We will here explain our study finding in regard to the association between nurses in private hospitals and substance use rate which exceeded their partners in public hospitals. The healthcare services in Jordan is provided by private and public institutions, therefore it is essential to explore the adaptation of both public and private healthcare institutions during the pandemic. This paper pointed a finger towards the institutional resilience in the health sector and its effects on the employees resilience behaviors during COVID-19. It could be hypothesized here, and left for further future research testing, that the public sector was more resilient than its private partner; and the ability to expand resources, money expenditure and staff mobilization were more adaptable in the public sector. Therefore, the public employees were possibly less stressed and more resilient than their partners in the private sector. This issue was directly reflected on the substance use patterns (41, 42, 43, 44).

Differences in Nurses’ Resilience between Substance Users and Non-users

Nurses suffer job related stress and this has a negative effect on resilience patterns; that is their ability to manage life and work demands under diversity and hardship (45). Problems that negatively affect nurses’ resilience have serious consequences, such as decreased nursing professionalism, poor quality of care, increased social and financial losses, decreased job satisfaction, increased turnover and substance use (46, 6, 9, 10). Resilience is a positive concept that allows nurses to overcome stressful situations and adapt positively, resulting in the maintenance of their psychological well-being and mental health (47). Resilience is emerging as an important concept for reducing the psychological burden of nursing profession. Timely studies of resilience can ameliorate nurses’ negative job consequences caused by their traumatic experiences. One targeted consequence of those, is substance use (48).

Jarrad et al (2018) had explained substance use using the resilience model. They stated that there are several coping styles by which a care giver respond to stressful situations. The negative coping styles include avoidance-oriented coping (replacement behaviors to substitute the problem); which basically result in care giver self-destructive behaviors of substance use (10). The resilience model assumes that resilient people will not seek less adaptive ways to solve their problems and face emotional trauma (17, 18). On the contrary; those who are less resilient may resort to less adaptive techniques to manage their stressors (19, 20). Such techniques include forms of substance use that extend to misuse or addiction (21). In that sense, our study finding that non-users scored higher in resilience mean scores for all substance types than substance users could be easily comprehended .

COVID-19 years came with burdens imposed on health and nursing professional bodies. Those entities were struggling prior to that from huge legacies of stress inducing variables such as heavy work-loads, increasing case complexities, introduction of new technologies, lack of managerial support and insufficient reward and psychological rehabilitation/consultation systems. In that sense we can understand why would some health professionals fall into the trap of becoming less resilient in the face of such complexities, and why some of them would be seized in the substance use maze.

Recommendations

We would recommend further research to be done in the area of nurses substance use and resilience patterns. Qualitative approach and/or mixed methodology is advised in this regard in order to enrich future findings. Eventually, health care systems are encouraged to adopt resilience enhancing programs, and strong consultation and rehabilitation services to help their employees manage stress, emotional pain and psychological trauma, build more adaptive coping skills, and discourage maladaptive behaviors of smoking, alcohol, and substance use.

Limitations

This study had adopted convenient sampling because of the sensitivity of the researched topic. Random sampling would be of added value in the future to enhance generalizability. Besides, the substance use was measured utilizing self-reported questionnaire which may have contributed to downsizing the exact substance use percentages of illegal illicit drugs. Alternative methodologies may be encouraged to better approximate exact use numbers.

Author contributions

RJ, NM, EH, AM and DJ, contributed to the research questions and conceptual design of the study. RJ supervised, applied and enhanced the whole research process. NM conducted all data management and analysis. EH drafted the Methods, Results and Discussion. AM facilitated the data collection, verified data and edited the manuscript and DJ reviewed literature and drafted the Introduction. The research is approved in its current format by all authors.

Acknowledgements

The authors send sincere thanks to the following parties for their full support and collaboration: The University of Jordan, the Ministry of Health in Jordan and the private hospital sector.

Funding

This research work is funded by the Deanship of Scientific Research in the University of Jordan.

Data availability

Data are saved on the primary researcher’ lab top and will be provided upon need.

Declarations

Ethics approval and consent to participate

This study received ethical approvals from the following parties: the Ministry of Health in Jordan, the private and academic hospitals ethical boards, the Deanship of Scientific Research in The University of Jordan and the ethical committee in the school of Nursing in The University of Jordan. An informed consent was signed by approving nurses after full explanation of their participation rights, the purpose and the methods of the study. We declare that this study is based on questionnaires and didn’t include any human or animal nor tissue based trials.

Competing interests

Hereby, the authors confirm that there are no competing interests of any kind.

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Nurses substance use and resilience patterns

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Abstract

Introduction

Methods

Study Sample

Measures

Analysis

Results

Associations Between Nurses Gender and Substance Use

Associations Between Nurses’ Health Sectors and Substance Use

Differences in Nurses’ Resilience between Substance Users and Non-users

Conclusion

Recommendations

Limitations

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References

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