Health and Social Care in the Community (2007) 15(3), 238 245

doi: 10.1111/j.1365-2524.2006.00683.x

Too frightened to care? Accounts by district nurses working with clients who
Blackwell Publishing Ltd

misuse substances
Sue Peckover PhD MMedSci HV(Cert) PGCertEd(Health and Social Care Practice)1
and Robert G. Chidlaw MSc RMN CPN RNT CertEd DipCounselling2
1

School of Health and Human Sciences, University of Huddersfield, Huddersfield and 2School of Nursing and Midwifery,
University of Sheffield, Rotherham, UK

Correspondence
Sue Peckover
School of Health and Human Sciences
University of Huddersfield
Queensgate
Huddersfield HD1 3DH
UK
E-mail: S.Peckover@hud.ac.uk

Abstract
Drug misusers have complex health and social care needs, and experience
considerable difficulties in accessing the assessment, care and treatment that
they require. Despite the development of specialist services in many parts of
the UK, substance misuse is often marginalised within mainstream general
healthcare, and many practitioners are unprepared for the challenges of
working with this client group. The present paper reports findings from a
qualitative study that aimed to explore district nurses understandings and
practices in relation to discrimination and inequalities issues. The research
took place during 2003 in two city-based primary care trusts in the North of
England. Semistructured interviews were undertaken with 18 G grade
district nurses. The authors present findings that highlight some of the
challenges and tensions district nurses encounter when providing care to
clients who misuse substances. The discourses of prejudice and risk were
intertwined throughout the data, and served to shape service provision for
clients who misuse substances. This was reflected in the district nurses
accounts of their own practice and that of other services, suggesting that
these clients receive suboptimal care. The discourse of risk was also used
by district nurses to construct themselves as vulnerable, and this helped to
explain some of their own practices of care provision. Many participants
acknowledged their limited knowledge and experience of working with this
client group. There is an urgent need for district nurses and other health
professionals to develop their practice with these clients, who may present
as both vulnerable and dangerous, in order to ensure that care is provided
equitably and safely.
Keywords: district nursing, prejudice, stereotyping, substance misuse
Accepted for publication 14 September 2006

Introduction
Substance misuse is an important healthcare issue.
Clients who misuse substances often face difficulties in
accessing appropriate and timely health services such
as primary care, and despite having complex health and
social care needs that increase their vulnerability, many
face prejudice and discrimination from health professionals (Newcombe 1993, Rassool 1998, Hunt & Derricott 2001, Midgely & Peterson 2002). This reflects wider
societal discourses about substance misusers who are
238

often stereotyped as disruptive and dangerous. Specialist

services in the UK, such as mental health and drug treatment services, have improved provision and care for
clients who misuse substances. However, there remain
gaps in non-specialist services (Department of Health
1999), which often marginalise the issue of substance
misuse.
This is further aggravated by the illegal nature of
much drug use, which means that it often remains
hidden or not spoken about (Hunt & Derricott 2001,
p. 191). Understandings about substance misuse and

2007 The Authors, Journal compilation 2007 Blackwell Publishing Ltd

District nurses and clients who misuse substances

the language used also shape how these clients and

activities are constructed. For example, terms such as
junkie or smackhead, and media reporting of links
between problem drug use and criminal activity contribute to negative attitudes about this client group
(Hunt & Derricott 2001).
The language used can reflect value-based judgements about drug-taking behaviour. Terms such as
abuse have now largely been replaced by use and
misuse. Here the former refers to . . . drug taking that,
although it has some risk, is not necessarily wrong or
dangerous, while the latter refers to drug taking that
impacts upon health or social functioning (Drugscope
2002, Hunt & Derricott 2001).
Although drug misuse is constructed as a public
health issue, there are difficulties in establishing the
extent of the problem. This is largely because of the
illicit nature of drug-taking, and the often fragmented
ways in which users and services intersect. In the UK,
recent policy developments have led to a greater
integration of health and criminal justice services, and
although this has raised the profile of substance misuse
across agencies, there remain ongoing tensions in how
these clients are managed. This may reflect wider
debates about care or control, which are key social
policy discourses and are central to understanding
contemporary tensions in mental health provision (Godin
2000). These may have less resonance across general
healthcare services and help to explain some of the
problems these services face when managing clients
who misuse substances.
As Day & Crome (2002) have pointed out, the
emphasis upon specialist services, such as addiction
services and methadone programmes, has deflected
attention away from ensuring that these clients receive
adequate physical healthcare. There has been little
discussion of this in the literature, although Rassool
(1993, 1998), writing from a nursing perspective, has
pointed to the challenges facing this professional group
in meeting the healthcare needs of these clients. Rassool
(1993, 1998) suggested that, in addition to providing
care, nurses should develop their work to include, for
example, advocacy, health promotion, consultancy and
leadership roles. Whilst this may begin to ensure
equitable and effective care for this client group, developments in nurse education and training are also required
because substance misuse is marginalised within
healthcare curricula and knowledge bases (Rassool 1993,
1998, Cranfield & Stoneham 1996, English National
Board for Nursing, Midwifery and Health Visiting 1997,
Peterson 2002).
The present paper focuses upon the British district
nursing service, which plays a key part in primary care
provision. District nurses work takes place largely in

clients homes, where they provide a range of general

nursing care. District nurses manage small teams of
qualified nurses and support workers, and their role
involves assessing, delivering and evaluating the care
provided to their clients. Assessment, advocacy and
communication are important elements of district
nursing practice (Goodman et al. 1998, 2003, Ross &
Victor 1999, Lock & White 2001, Kennedy 2002, Speed &
Luker 2004).
Recent policy developments have seen the emphasis
of care shift from hospital to community settings, and
district nurses now have increased clinical and caseload
responsibilities, providing care to a wider and more
diverse range of clients (Audit Commission 1999, Lock
& White 2001). Previous research has pointed to
inequalities in district nursing provision reflecting both
organisational constraints, such as the size and location
of nursing teams, and professional constraints, such as
the continued emphasis upon individualised care
(Gerrish 1999, 2000). Research has also suggested the
complex ways in which personal prejudice impacts
upon and is shaped by professional practice, and the
difficulties practitioners such as district nurses face
when managing these issues in everyday practice
situations (Hart & Lockey 2002, Aranda 2005). No previous literature has been located which has considered
district nursing work in the context of providing care to
clients who misuse substances. This is the focus of the
present paper.

Subjects and methods

The research upon which the present paper is based
explored district nurses understandings and practices
in relation to discrimination and inequalities. Although
the study identified many issues, such as the complexities
of working with culturally diverse communities and the
tensions between maintaining an individualised focus
upon clients whilst also remaining cognizant of wider
community and structural issues impacting upon
health, these are not addressed within this paper, which
focuses specifically upon a subset of the data relating
to district nursing work with clients who misuse substances. This theme was not a specific a priori concern of
the study, but one that emerged from within the data,
reflecting the discussions of many district nurse
respondents about this area of work. The research was
undertaken by authors who have backgrounds in community mental health nursing and health visiting, and
at the time of the study, both were involved in teaching
anti-discriminatory practice issues to pre- and postregistration nursing students.
The research was undertaken during 2003 in two
city-based primary care trusts (PCTs) in the North of

2007 The Authors, Journal compilation 2007 Blackwell Publishing Ltd

239

S. Peckover & R. G. Chidlaw

England. These were selected because they provided

healthcare services to a culturally diverse and largely
urban population marked by high levels of social disadvantage. The study received ethics and National Health
Service research governance approval (Department of
Health 2001).
The research aimed to explore the understandings of
qualified district nurses who had a role in managing the
overall caseload, the wider community nursing team
and its resources at the time of the study. These issues
were considered relevant to the focus of this exploratory study and informed the overall sampling strategy.
At the time, there were only 22 qualified district nurses
employed by the two PCTs, and therefore, they were all
invited to participate in the research. Each qualified
district nurse was sent an information sheet and further
details about the study. The researchers also attended
staff meetings to discuss the investigation further. In
total, 18 qualified district nurses participated in this study.
Data was collected using semistructured interviews
that focused on exploring the following key areas with
district nurses: their understandings and practice experiences of discrimination or inequality issues facing
their clients; the district nursing role in helping such
clients in terms of delivering care and allocating
resources; and their views about influencing the strategic direction of their organisation in relation to tackling
issues of inequality and discrimination in the communities where they worked. Prior to each interview,
which were all audio-tape-recorded and transcribed,
the study was further explained and a consent form was
signed.
The study was informed by a qualitative methodology
that enabled an in-depth exploration of district nurses
understandings and practices in relation to equality
issues. The data analysis that was undertaken by both
researchers involved a number of approaches (Coffey &
Atkinson 1996, Silverman 2000). The data categories
were both literal and interpretative, with some reflecting a priori concerns and others emerging from the data
inductively (Strauss 1987). Case studies and accounts
of practice within the interview data were also highlighted. These were used to both explain and compare
across different aspects of the data set. This process of
comparison enabled the researchers to test emergent
understandings by, for example, looking for negative
instances, challenging the emerging interpretation and
searching for alternative explanations, thus further
strengthening the rigour of the analysis (Marshall &
Rossman 1999, p. 157, Silverman 2000). Throughout the
study, attention to the situated and textual nature of
interview data enabled the researchers to develop interpretations about how district nurses construct meanings within their accounts (Silverman 1993, 2000).
240

The findings described in the present paper draw

upon the data relating to district nursing work with
clients who misuse substances. The authors use data
extracts from those district nurse respondents who had
experience of providing care for clients who misuse
substances and who raised this issue within the interview discussions. There was a high degree of consensus
amongst these respondents, who worked in different
geographical localities across both the PCTs. The data
extracts are identified by a coded number (e.g. DN1 and
DN2) in order to ensure anonymity. The findings focus
upon the discursive construction of clients and practitioners, and the ways this becomes constituted within
everyday practices.

Results
District nurses were providing community-based care
for substance-misusing clients with clinical conditions
such as leg ulcers or wounds that are slow to heal,
usually as a result of vascular system damage and
infections associated with injecting drugs (Day & Crome
2002). Their work with substance-misusing clients was
a small part of their workload, but one that was increasing as a result of a growth in overall drug use. Although
the exact prevalence is unknown, estimates suggest
there are more than 4000 problem drug users within the
city (Frischer et al. 2004), with less than half receiving a
structured drug treatment programme. At the time of
the present study, crime figures for England and Wales
indicated a 6% increase in serious drug-related offences
(Mwenda & Kumari 2005).
District nurses accounts of clients who misuse
substances were heavily interwoven with notions of
prejudice and stigma, describing aspects of their own
practice, the service provision of others, and wider
societal and community views about substance users:
Alcoholics and drug users tend to be discriminated against.
(DN16)
Theres problems in the area with drug use and I think sometimes drug users can be all sort of, as they say, tarred with the
same brush . . . You see it that GPs [general practitioners]
arent happy to take them onboard, you know, they dont
want them on their caseloads. (DN10)

One district nurse felt that even though GPs may be

providing primary medical services to substance misusers, their decisions to not participate in prescribing
initiatives (Department of Health 1999, Keen et al. 2000,
Ford 2004) mean that these clients receive suboptimal
care:
And they have poor access to the GPs here because the GPs
dont participate in the drug regimes and the methadone

2007 The Authors, Journal compilation 2007 Blackwell Publishing Ltd

District nurses and clients who misuse substances

projects, so they all have to go to the clinics for that to be give

methadone and what have you . . . And so, really, once again,
theyre quite disadvantaged really. (DN9)

The difficulties substance misusers faced when accessing other forms of health service provision were also
highlighted. This was because of their lifestyles, and a
perception that their conditions were self-inflicted as a
result of drug use. The following account refers to the
discrimination experienced and poor care received by a
client who had frequent hospital admissions because of
vascular damage from intravenous drug use:
And I am sure that he is discriminated against. Well, I know he
is, when he goes into hospital, when he comes out the treatment he has described because he is trying to come off the
drugs he is on a drugs project and everything. (DN4)

The wider discourse of prejudice and discrimination

interwoven throughout the above accounts also served
as a frame of reference for district nurses accounts of
their own practices.
All the district nurses drew upon a discourse of risk
rather than need when describing working with
clients who misuse substances. This is illustrated in the
following accounts, which emphasise the aggressive
behaviour of clients. While participants acknowledged
that this is a result of drug dependency, it is constructed
as a risk to the service provider, rather than considering
the drug dependency to be problematic or harmful to
the client:
From the experiences that weve had, it can be sort of the
aggression. The aggression that can come if theyre not getting
the drugs that they want, or theyre not getting the treatment.
Weve experienced that firsthand up here, and that is quite
daunting, quite scary. And for us going in to visit people on
our own. (DN10)
There was one chap who wanted a dressing doing at one stage,
and we didnt know he had a drug problem at the time. I went
in as a first visit, as a one-off they wanted me to go there and
then. So I went, but on getting there, it wasnt really the dressing he wanted doing, it was some methadone he wanted. So
I felt very vulnerable in that position because he was quite
aggressive. So then we went in twos after that, even though it
didnt really warrant it once hed settled down. But I think the
stigma was there and it was, Wed better go in twos just to be
on the safe side. (DN13)

In both these accounts, the respondents drew upon

the notion of aggression to frame the behaviour of the
substance misuser, who is constructed as risky. This
serves as a device to both explain respondents practices
with substance-misusing clients, and at the same time,
obscure other ways of knowing or understanding. Here
the absence of any discourse about care or care needs
is particularly striking, both because this is such a key

professional discourse within district nursing (Kennedy

2002) and because substance misusers have substantial
unmet health needs (Day & Crome 2002). However, the
construction of substance-misusing clients as risky
obscures understandings that they could also be vulnerable and in need of care. Instead, faced with a risky
client, it is the care giver who becomes vulnerable.
These discursive constructions of substance misusers
as risky and district nurses as vulnerable provides a
means of accounting for their everyday practices when
working with this client group. This includes visiting in
pairs, which is explained for reasons of personal safety,
and not for clinical or care reasons. It also accounts for
why such clients may receive a briefer and more taskoriented service from district nurses than is offered to
other clients:
. . . [T]he drug users, I think they get . . . I mean, its awful to
say, probably not a minimal service, but youre sort of more in
and out, and you wouldnt necessarily spend the time . . . I
think its human nature, you just sort of do what youve got to
do, and because theres a stigma attached, there may be some
safety issues, you tend to go, do what youve got to do and
then youre out again. (DN13)

These discourses of risk and vulnerability are used

to explain the provision of a minimal service to clients
who misuse substances. The emphasis is on getting the
job done, and it is clear that this is a very task-oriented
and clinically focused job. This contrasts with
respondents discussions of their work with other
clients, where they constructed their professional identities in terms of caring and good communication, placing
greater emphasis on this than clinical activity.
However, some respondents did suggest that their
responses to substance misusers, because they are
constructed as risky, mean that these clients receive
a briefer contact and a poorer-quality service. This
is because the briefer time spent with the client compromises the process of getting to know them, which is
an essential aspect of district nursing practice (Luker et al.
2000, Kennedy 2002, Speed & Luker 2004). As a result,
important aspects of the clients emotional, physical or
social care needs may be missed.
Alongside this was a marked absence of any discussion of clients who misuse substances in individual or
personal terms. This apparent lack of personal engagement was in stark contrast to the respondents discussions of their work with other clients. This suggests that,
for many respondents, the stigma of substance misuse
obscured the personhood of the client, a process of
discriminatory practice described as dehumanisation
by Thompson (1998, pp. 8687).
The discourse of substance misusers as risky and
the district nurse as vulnerable also served to shape

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S. Peckover & R. G. Chidlaw

the spatial aspects of district nursing provision for these

clients. There were many examples of respondents
describing providing care in a clinic or surgery setting
rather than at the clients home, although it appeared
that these decisions were based on risk borne of prejudice rather than a systematic risk-management approach.
In the following data extract, the respondent is
trying to explain why clients who misuse substances
may be asked to attend a surgery or clinic appointment
to have their clinical needs addressed:
Its really difficult to explain. I dont think we are sort
of . . . and although we provide the service its . . . I suppose
different things come to mind, whether its sort of your risk
management coming into play. But somebody in that situation
where there was a perceived or real problem within the home,
safety-wise, you wouldnt, you would say, Right, you have to
come to the surgery. Where maybe it was just a perceived
threat that wasnt really there. I think its easier to jump onto
that when probably theres nothing there at all. (DN11)

A similar issue is highlighted below by a respondent

describing contact with a substance-misusing client:
One of my interests is leg ulcers and I do the clinic at [name of
health centre]. And there is one young lad who is there. The
district nurse couldnt carry on with him, he does a lot of drug
abuse, and going to his house, there is a lot of drug addicts
living there. So he comes to me at the clinic. And when he
came, I just said, Look, dont mess us about. I really, I was not
judgemental. But it has worked really well. It is not just me,
there is another nurse who works there as well. And we have
done it together. But it is working in partnership . . . I must
admit, he is the youngest person that I see. It is not often you
[see] a 20-year-old with leg ulcers, but his legs dont look like
a 20-year-olds though. (DN4)

In the above account, the respondent suggests that the

discourse of risk, rather than clinical reasons, determined the location of the service. This account is the
only one in which there is a glimpse of the humanity of
clients who misuse substances, although, notably, the
age of the client is emphasised here.
Whilst the work of district nurses can be diverse
depending upon the populations served, and local
health and clinical issues, the majority of their workload
is concerned with the provision of intermediate care,
palliative care and care of older people (Goodman et al.
1998, 2003, Ross & Victor 1999). Thus, providing general
district nursing services to clients who misuse substances
is not a core role for those working in community
practice. Here, of course, it is important not to fall into
essentialist notions relating to substance misusers, since
this is not a fixed or mutually exclusive category.
Clearly, clients who misuse substances may also be
needing palliative care, and/or be older people with
care needs (Williamson 2002). However, and taking
242

account of multiple and changing presentations, substance misusers do represent a small minority of district
nursing work, particularly when compared with the
caseload populations of other health professionals such
as community psychiatric nurses (CPNs). This was
highlighted by the following respondent:
. . . I think its because we dont deal with a lot of that, its
usually dealt with by the drug people or the CPN, something
like that. We are not too knowledgeable about it and the issues
surrounding it. We are sort of on the periphery, doing other
things. So I think it would probably be lack of knowledge and
understanding on our part that would cause us to be discriminatory with that client group. (DN1)

Constructing district nurses as professionals who lack

specialist knowledge of substance misuse helps to
explain the limitations of the service that they provide
to this client group. Again, the data suggest that,
although competent clinical nursing care is provided,
holistic or empathic aspects of care may be lacking.
However, in describing district nurses as sort of on the
periphery, doing other things, the above respondent
uses the discourse of specialist knowledge to suggest
a marginal role for district nurses, and one that is
reduced to a clinical intervention such as dressing a
wound, whilst, at the same time, placing other workers
centre stage.
This is again used in the following account, where
the respondent refers to her limited knowledge of
mental health:
I think, with issues around alcohol misuse and drug misuse, I
feel very inadequate. So I really dont feel that I can assess . . . I
might be able to know the risk factors, but I wouldnt really
know much about how . . . like going to help them, other than,
perhaps, referring to the mental health services, and that
probably would be as far as my remit would go. (DN12)

Although acknowledging that clients who misuse

substances may have unmet needs, the discursive
construction of district nurses as lacking in specialist
knowledge helps to explain their limited role when
working with this group of clients. Instead, ongoing
responsibility is discursively transferred to specialist
workers with mental health expertise. The privileging
of the mental health over the physical health aspects of
problem drug use is interesting, and occurs despite the
participants experiences of providing clinical care for
embodied physical health complications such as venous
leg ulcers.
Alongside this acknowledgement of a lack of
specialist knowledge was a recognition the respondents
would benefit from further training or education to
enable them to improve their working practices with
clients who misuse substances. This is illustrated in the
following data extract:

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District nurses and clients who misuse substances

We have had one or two cases with the drug users in this area,
and its educating people that, you know, theyre not all sort
of in a pigeonhole and theyre going to behave like this, and
just making people aware that these people arent all scary and
that theyve got a need there, and we can meet that without
any problems. But sometimes theyll say, Oh, this patient is a
drug user or a drug problem, and, oh, you know. So I think its
about education. (DN10)

A number of respondents suggested that the district

nurses lack of knowledge and experience of working
with substance misusers needed to be addressed to
ensure that these clients received a more equitable and
holistic service. The provision of training would also
enable district nurses to feel safer and more confident in
their practice.
Study limitations
Whilst these findings highlight important issues for the
practice and education of nurses to enable them to
develop their work with clients who misuse substances,
the present authors acknowledge the study limitations.
The findings presented here are part of a wider project
that examined district nurses understandings and
practices in relation to discrimination and inequality
issues. Whilst the research used in-depth interviewing
and a qualitative methodology to address the research
questions, these were not specifically focused upon
substance misuse. If this had been an a priori concern,
some of the findings may have been more detailed. For
example, the current data set lacks detail about the
respondents specific educational and training experiences in relation to substance misuse issues, and this
gap needs to be addressed in future research. The study
was also based on a small sample of qualified district
nurses, and while appropriate for the overall research
aims, there are limitations of both size and diversity. In
particular, the inclusion of registered nurses working in
community teams who do not have a specialist district
nurse qualification would add a broader perspective to
any future research undertaken in this area.

Discussion
Escalating rates of drug misuse make it increasingly
likely that district nurses and other general nurses will
be involved in the provision of healthcare for clients
who misuse substances (Rassool 1998, Hunt & Derricott
2001). Given the clinical complexities and impact of
illicit drug use it is likely that many of these clients will
not only be marked by the stigma of drug misuse, but
also be facing considerable health issues arising from
this (Day & Crome 2002). Thus, it is important for
district nurses and other healthcare professionals to be

adequately prepared to ensure that they are able to

provide equitable and appropriate services to this client
group.
The present findings suggest that district nurses
were ill-prepared for working with substance misusers.
Prejudiced and stereotypical views influenced their
constructions of these clients as risky, and this was
interwoven throughout the interview data. This clearly
shaped the practices of district nurses when working
with clients who misuse substances, leading them to
make shorter visits and visiting in pairs, thus highlighting the ways in which they act as gatekeepers to their
own service. It also constrained their contact with
substance misusing clients, suggesting that they were
non-specialist, and therefore, unable to meet their
clients needs other than by addressing a specific clinical
issue. In this way, the care offered to substance-misusing
clients became subject to a reductionist approach, which
was in sharp juxtaposition to the descriptions of care
offered to other clients and to the ideal of holism discussed by the respondents. Given the likely increased
health needs of substance-misusing clients, particularly
those with clinical manifestations such as vascular
damage caused by injecting drugs, the descriptions of
minimal and limited district nursing practice with these
clients is suggestive of an inverse care law (TudorHart 1971).
The absence of a professional discourse about caring
for clients who misuse substances within district
nursing may have contributed to constructing these
clients as other, forcing the subjects to fall back on
stereotypical and prejudicial attitudes. However, these
were not hidden by the respondents, but highly transparent throughout the research, reflecting what Aranda
(2005) referred to as a dangerous self. This arose from
a study of community nurses discourses in relation to
equalities issues, and described the ways that occasionally community nurses . . . threatened equality of care
because they were actively implicated in perpetuating
oppressive care or discriminatory practices and reinforcing inequalities (Aranda 2005, p. 135). However,
in the present study, and in contrast to the narratives
reported by Aranda (2005), district nurses openly
revealed their discourses of prejudice and discrimination about clients who misused substances, making the
dangerous self highly visible.
Writing in the context of nursing and midwifery
work with minority and disadvantaged client groups,
Hart & Freeman (2005) recognised that dealing with
equality issues is challenging for many practitioners.
The above authors used the term professional selfpreservation to describe how practitioners attempt to
maintain their own emotional health when dealing with
difficult and challenging practice situations. Some of

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S. Peckover & R. G. Chidlaw

the ways in which this is achieved include labelling and

stereotyping, the creation and maintenance of boundaries in professionalclient contact, and the dispersal of
professional responsibility (Hart & Freeman 2005, p. 507).
Interestingly, all of these were visible in the present
study of district nurses work with clients who misuse
substances.
The district nurses in the present study had little
clinical or educational experience that prepared them
for working with substance misusers, and this may
have contributed to their perceptions of this client
group. In describing their work, they often struggled to
find the person who was frequently obscured by the
stigma of drug misuse. This reflects previous research
with people with HIV, which found that the most disturbing examples of fear and stigmatising behaviour
involved healthcare workers from non-specialist units
who did not have everyday contact with people with
HIV (Green & Platt 1997). The above researchers found
that, as health workers had greater contact with this
client group, the stigmatisation reduced, and concluded
that the stigmatised individual is eventually accepted
as normal or at least ascribed an identity based on the
person and not the stigmatising characteristic (Green &
Platt 1997, p. 88).
As well as increasing their practice experience of
substance-misusing clients, there is a need for improved
education and training (Rassool 1993, 1998, Cranfield &
Stoneham 1996, English National Board for Nursing,
Midwifery and Health Visiting 1997, Peterson 2002).
This would enable district nurses and other health
professionals to critically reflect upon the ways in
which their knowledge and practice is shaped by wider
societal views and understandings about substance
misuse, and the impact that this has upon how they
approach their work with individual clients. In order to
achieve this, a reflective and critical engagement with
the complexities of working with this client group is
needed, one that acknowledges the tensions that arise in
providing care and managing risk to clients who may
present as both vulnerable and dangerous (Godin 2000).

Conclusion
In recent years, nursing has engaged with issues of
human difference, and there is a growing literature
highlighting the need for improvements in education
and practice to ensure the greater promotion of equity
(e.g. see Gerrish et al. 1996, Papadopoulos et al. 1998,
Scullion 2000). Alongside this is a growing interest in
nurses work with client groups marked by exclusion,
disadvantage or stigma (Mason et al. 2001, Hart & Lockey
2002). Despite many specialist practice developments,
research suggests that nurses often hold negative and
244

prejudicial attitudes towards some clients; for example,

people with tattoos (Stuppy et al. 1998), clients who
self-harm (McAllister et al. 2002) and people with HIV
(Green & Platt 1997). The discrimination and prejudice
experienced by clients who misuse substances from
healthcare workers has been widely documented
(Jeffrey 1979, Rassool 1998, Hunt & Derricott 2001).
The present study builds upon this work, focusing
upon substance misusers and district nursing practice
in particular. It illustrates how both clients and practitioners are discursively constructed, and how these
impact upon and shape the everyday practices of
district nurses. Whilst remaining cognizant of the challenges of working with substance misusers, the authors
suggest that there is an urgent need for district nurses to
improve their service responses to this client group.
This requires educational, policy and practice developments in order to ensure appropriate and equitable care
delivery and risk management.

Acknowledgements
The authors would like to thank the C.A.R.E.R.
(Community, Ageing, Rehabilitation, Education and
Research) Department of Sheffield University School of
Nursing and Midwifery for a small grant that facilitated
this research.

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