Nipissing University BScN Learning Module
Best Practice Guideline:
Engaging Clients Who Use Substances
(RNAO, 2015)
The Nipissing University BScN program is undergoing a pre-designation to become a Best Practice Spotlight Organization (BPSO). This project is funded by the RNAO in conjunction with the Ministry of Health and Long Term Care.
Disclosure: This presentation is based on the RNAO best practice guideline; Engaging Clients Who Use Substances
First Year
Knowledge of BPG, and assessment using BPG’s (Introduce BPG order sets).
Second Year
Clinical exposure to application of BPG’s
Third Year
Knowledge and use of BPG’s in complex settings.
Fourth/Fifth Year
Application of BPG’s in complex scenarios (critical thinking).
How to Use BPG's based on your Academic Year- A General Guideline
When reviewing this guideline for application, it should be applied in accordance with the individual, the organizations needs and the practice setting. This guideline provides an overview of supports, and appropriate structures in order to provide the best possible evidence based (EB) care.
(RNAO, 2016)
(RNAO, 2015)
Substance Use
(Ministry of Health Promotion, 2010; Rassool, 2010)
The administration or ingestion of psychoactive substances. Examples of theses substances include; tobacco, alcohol, illegal drugs, caffeine, medications, glues, and solvements. These substances can either be harmful or beneficial depending on the context of use, the method, frequency, and the substance that is being used.
One thing to keep in mind...
Not ALL substance use leads to difficult behaviour, it is circumstantial. Specific situations, depending on the type of substance consumed, can further lead to psychological and physical health problems. Substance abuse has no correlation to an individuals socioeconomic status or geographic location, it has the power to affect anyone.
Substance Use Disorder
Commonly referred to as 'addiction'
Following the DSM-5, the defination is "a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues using the substance despite significant substance related problems” (APA, 2013, p. 483).
Based on pathological displays of behaviour: Risky use
Pharmacological criteria Social Impairment Impaired control
(RNAO, 2015)
Three Most Commonly Used Psychoactive Substances in Canada
Alcohol Cannabis Tobacco
Globally, Canada has the second highest level of prescription opiod use
Examples; Morphine Oxycodone Codeine
(RNAO, 2015)
The Gap
(Pirie et al., 2014).
There is a gap between the number of individuals with subtance abuse disorders along with the number who are accessing resources to recieve help with their substance abuse disorder.
In 2012- 4.4% of Canadians were identifed to have a substance use disorder. Only 0.4% went and accessed publicy funded services and interventions.
This proposes a need for better identification of these services and awareness of substance use disorders.
Risk Factors of Substance Use Disorders
Biological or physiological vulnerability (ex. PTSD, Mental or physical illness) Genetics
Internal factors (ex. coping skills)
External psychosocial factors (ex. stressors, trauma, family/friend situations)
Social determinants of health
(Ministry of Health Promotion, 2010; RNAO, 2009).
Physiological vs Physical Dependence
(APA, 2013; RNAO, 2009)
Physiological Dependence: a pattern of substance use and craving, due to the effects of the substance - most often triggered by an environmental cue of previous use
Physiological Withdrawal Symptoms: anxious, irritable, or mood lability
Physical Dependence: a tolerance is developed to a substance, so the individual increases the amount that is consumed in order to reach the desired effects
Physical Withdrawal Symptoms: Nausea, vomitting, palpitations, and tremors.
Process of Developing a Substance Use Disorder
(APA, 2013; RNAO, 2009)
Stigma Around Substance Use Disorder
(RNAO, 2015)
Martin & Johnston (2007) describe a stigma as a social process that is depicted with patterns of blame, rejection, devaluation or exclusion as a result of an anticipation or past experience to conclude to a social judgemet about an individual or group.
Substance abuse disorders are often grouped by society from a moral or criminal perspcetive rather then as a health concern.
Livingstone (2010) notes that stigma leads to poor outcomes including: delayed recovery
poor mental and physical health delayed reintegration
increased involvement in risky behaviour
barriers to engagement diminishing outcome of therapeutic interventions
(Toward the Heart, 2019)
Frameworks Used within Guideline
1. Social Determinants of Health
(RNAO, 2016)
When working with individuals who experience substance use disorders, it is important to identify the social determinants that affect their overall health.
Consider the individuals: Social Supports
Income and social status Personal Coping Skills Education
As nurses there is a responsibiliy of incorporating these determinants into a patients plan of care, including assessments, plans, interventions, and their overall goals.
2. Population Health Promotion Model
(Hamilton and Bhatti, 1996)
The purpose of population health promotion is to reduce the health inequities faced by large groups and in turn improve a populations overall health.
This model demonstrates how the health of a population can be improved with the use of health promotion strategies and interventions that work specifically on the factors and conditions that affect a populations health.
3. Transtheoretical Method of Change (TTM)
(Prochaska & DiClemente, 1984)
This model was designed to describe the process of behaviour change.
Keep in mind that change is indvidualized and non-linear.
Utilizing the TTM model, allows for nurses to assess the individual based on the stage in which they are in the change process, engaging them in interventions related to their specific needs.
The purpose of harm reduction is to minimize the adverse affects of substance use disorder, without the individual abstaining from those substance, as harm reduction recognizes that substance use is complex in nature.
4. Harm Reduction
(CNA, 2011: Rassool, 2010; RNAO, 2009)
This framework is based on advocating for equal services and resources, while maintaining a non-judgemental attitude participating in this individuals care. It is designed for health practitioners to be involved in the care of these individuals and provide interventions in within their environment where the substances are used rather then take them out of that context. Nurses are able to follow this approach by meeting with clients in their environment and establishing goals with the client so they can be at the center of their plan of care, in turn further developing the nurse-patient therapeutic relationship.
Before this approach is used, it is crucial that nurses recognize their own biases and opinions towards substance use disorder.
5. Trauma Informed Approaches to Care
Many individuals who have experienced a traumatic event turn to substance use as a form of coping with their symptoms.
When working with these patients, using a trauma informed perspective is crucial as trauma is often a potential cause of substance abuse. This results in nurse-patient relationship that is free from violence and judgment, with a focus on collabortation.
(RNAO, 2015)
6. Cultural Competence & Cultural Safety
The RNAO (2009) describes cultural competency as the application of skills, knowledge, attitude, and personal attributes that nurses use to provide appropriate care to communities, groups, or individuals.
Nurses must continue to instil cultural competency in their practice, and make sure that there is no stereotypyning that can lead to further stigmatization or marginalization.
(RNAO, 2009)
7. Recovery Perspective
(SAMHSA, 2005; Snow, 2010)
Recovery is: Individualized A journey Internal change Ongoing Patient-driven
Recovery is a continuous process that involves many ailments including overcoming stigmatization, becoming engaged in social activities and within the community, accepting individual vulnerabilities, and working to regain hope, responsbility, and control in their life.
The recovery perspective is one that often occurs outside or following professional intervention as it is client-driven and an ongoing process, once the nurse addresses this it emphasizes the importance of the individuals long-term managment and particpation in their care.
Algorithm for Engaging Clients Who Use Substances
(RNAO, 2015)
The expert panel on this guideline created an algorithm that touches on all of the practice and education recommendations that should be implemented across practice settings. How the algorithm is used is dependent on client factors, the healthcare provider, and the health care environment,
Three Pathways:
Pathway 1: screening individuals to determine whether they are using substances
Pathway 2: brief intervention, plan of care, and assisting with supports
Pathway 3: comprehensive assessment, plan of care, intervention, and evaluation
Scope
(RNA0, 2016)
Best practice recommendations are provided in three areas:
As nursing students, the focus will be on practice recommendations.
It is benefical to be aware of the educational, and system, organization, and policy recommendations.
Gap Analysis
The difference between current knowledge/practices (what we are doing) and current Evidence Based Practices (what we should be doing).
Gaps can occur in knowledge, skills or practice.
Reflect on the following questions, and be specific:
Where is our current practice?
Where do we wish we were/where should we be? Why has this gap occurred?
How are we going to close the gap?
Performing a gap analysis on best practice guidelines is an essential part of reflecting on practice. When reviewing the recommendations identify where there are gaps in current practice or knowledge, and take the time to reflect.
(Anthony J. Jannetti, Inc. 2012)
Steps to Conduct a Gap Analysis
(Anthony J. Jannetti, Inc. 2012)
Recommendations
Engaging Clients Who Use Substances
1.0 Assessment
(RNA0, 2015)
1.2 For clients who use substances, use universal screening questions and/or an appropriate screening tool to determine the level of support required.
(RNA0, 2015)
2.0 Planning
(RNA0, 2015)
2.1 Build collaborative relationships with clients through the use of motivational interviewing techniques to develop the plan of care.
(RNA0, 2015)
3.0 Implementation
(RNA0, 2015)
3.1 Use brief intervention to collaborate with clients identified as at risk for or experiencing a substance use disorder.
3.2 Advocate for and support access to combined pharmacological and psycho-social interventions, as appropriate, and promote the appropriate use of combined interventions to improve wellbeing and health outcomes.
3.3 Engage youth and adolescents at risk for or experiencing a substance use disorder using family based therapies until recovery, as appropriate.
(RNA0, 2015)
4.0 Evaluation
(RNA0, 2015)
4.1 Reassess the effectiveness of the plan of care until the client’s goals are met.
(RNA0, 2015)
Listed below are the education and system, organization and policy recommendations related to this BPG for your reference
5.0 Education Recommendations
(RNA0, 2015)
5.1 Integrate theory and clinical practice opportunities regarding care of clients at risk for or experiencing a substance use disorder into the undergraduate education of nurses and other health-care providers.
5.2 Health-care providers participate in continuing education
to enhance their ability to assess and work with clients at risk for or experiencing a substance use disorder.
5.3 Nurses practice reflectively to enhance their awareness of their current and evolving attitudes, perceptions and biases, and values and beliefs when working with clients at risk for or experiencing a substance use disorder.
(RNA0, 2015)
6.0 System, Organization, and
Policy Recommendations
(RNA0, 2015)
6.1 Advocate for improved health outcomes by:
Increasing access to integrative and collaborative care for clients at risk for or experiencing a substance use disorder; and
Reducing health inequities by dedicating resources to preventing, treating, and supporting the recovery of individuals at risk for or experiencing a substance use disorder.
6.2 Organizations integrate prevention, assessment, and management of substance use and substance use disorders as a strategic clinical priority across all care settings.
6.3 Organizations integrate components of harm reduction and the social determinants of health into comprehensive, multi-faceted approaches to addressing substance use disorders
6.4 Organizations use knowledge translation processes and multi-faceted strategies to integrate best practices in the assessment and management of substance use and substance use disorders across all practice settings.
(RNA0, 2015)
Research Gaps and Further Implications
Substance use is a complex topic that still requires further research to identify further recommendations and validate the current ones. This will lead to improved patient care and outcomes.
(RNA0, 2015)
(RNA0, 2015)
Check out the Engaging Clients Who Use Substances Pocket Guide!
(RNA0, 2015)
References
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Anthony J. Jannetti, Inc. (2012). A representation: Incorporating a needs assessment and gap analysis into the educational design. Pitman, NJ: Author. Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and health promotion.
Retrieved from http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php#Developing
Livingstone, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review. Addiction, 107(1), 39-50.
Martin, N., & Johnston, V. (2007). A time for action: Tackling stigma and discrimination. Retrieved from http://www.multiculturalmentalhealth.ca/wp
-content/uploads/2013/10/tigma_TimeorAction_MHCommission.pdf
Ministry of Health Promotion. (2010). Prevention of substance misuse guidance document. Toronto, ON: Queen’s Printer for Ontario. Retrieved from http://www.mhp.gov.on.ca/en/healthy-communities/public-health/guidancedocs/PreventionOfSubstanceMisuse.PDF
Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing the traditional boundaries of therapy Malabar, FL: Kriger.
Registered Nurses’ Association of Ontario. (2015). Engaging Clients Who Use Substances (Rev. ed.). Retrieved from http://rnao.ca/
Registered Nurses’ Association of Ontario (RNAO). (2009). Supporting clients on methadone maintenance Treatment. Toronto, ON:Registered Nurses’ Association of Ontario.
Registered Nurses’ Association of Ontario. (2005). Risk Assessment & Prevention of Pressure Ulcers (Rev. ed.). Retrieved from http://rnao.ca/ Snow, S. (2010). Psychiatric and mental health nursing interventions. In W. Austin & M. A. Boyd (Eds.), Psychiatric and mental health nursing for
Canadian practice (2nd ed.) (pp. 198-213). Philadelphia, PA: Lippincott Williams &mental health nursing for Wilkins.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Substance abuse treatment for persons with co-occurring disorders.
Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64197/pdf/TOC.pdf
Toward the Heart (2019). Language Matters. Retrieved from https://towardtheheart.com/reducing-stigma