Nursing Care in Alcohol and Drug User Treatment Facilities

Abstract

Registered and advanced practice nurses are employed in substance user treatment facilities across the US and in most industrialized countries. Patterns of employment and job descriptions for nurses, however, are highly inconsistent and seriously flawed. Many regulatory system, legislative and government agency factors and to some degree, the nursing profession itself, sustain the flaws and limit the delivery of comprehensive care. Competencies linked to addictions nursing best practices are often underutilized because of narrow job descriptions. This results in limited health and nursing service delivery to vulnerable populations receiving treatment in these government funded programs. This article highlights the increasing demand for the delivery of integrated care to psychiatric and substance using populations. The author considers factors which stake holders can influence to change flawed employment patterns and limited access to comprehensive care for substance users.

Keywords:

• nursing, integrated care
• substance users
• regulatory systems
• job description
• best practices
• comprehensive care

Declaration of Interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.

GLOSSARY

• Best practices: Exemplary behaviors modeled into processes. These are ethical, legal, fair, and applicable to anyone within an organization or a profession. In health care, practices derived from research evidence, clinical judgment, consumer preference.

• Comprehensive care: Care that addresses health and illness care needs ranging from prevention, early intervention, episodic medical care to long term care, rehabilitation.

• Integrated care: The systematic coordination of general and behavioral healthcare. Integrating mental health, substance abuse, and primary care services. http://www.integration.samhsa.gov/about-us/what-is-integrated-care.

• Job description: A list that a person might use for general tasks, or functions, and responsibilities of a position.

• Nursing: Diagnosing and treating of human responses to actual or potential health problems through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist or other licensed health care provider (New York State Office of the Professions, 2010).

• Regulatory systems: State and federal government agencies which proscribe standards, licensure and performance criteria for occupations, professions and agencies within the health care delivery system.

• Substance users: Persons who use, misuse or become dependent upon alcohol, tobacco and/or other drugs which have psychotropic properties.

Notes

¹ The issue of the quality of care/treatment is rarely considered in the broad area of substance user treatment. The interested reader is referred to Magura (2000).

² The reader is asked to consider that substance use disorder drug is a relatively new diagnostic category (American Psychiatric Association, 1995, 2013), which is the outcome of a recent check-listing process of medicalizing and “symptomizing” a range of human behaviors based upon expert committee consensualization of perceptions, judgments, and decision-making. It is a labeling process based upon 11 criteria (American Psychiatric Association, 2013) which deal with time, a person's experiences, impaired judgment, pro-social role malfunctioning, negative effects on a range of pro-social activities and the introduction, and dependence, upon two concepts-–tolerance and withdrawal. These terms represent the development of “drug” use-related processes which are not delineated in terms of their pharmacological actions on the micro-cellular level from a macro “drug experience” which is the outcome of the dynamic interaction between the actual active “natural” or man-made chemical, the user and the site of use at a given point of time (Zinberg, 1984). The substance use disorder is not evidence-informed. Nor are any of the other diagnoses in this pathologizing nosological system. A useful diagnosis, which is the outcome of collecting relevant materials over time, and which are culture-context and situation-sensitive, in order to make a needed relevant decision, should, at the very least, enable an understanding of etiology, prognosis, and process of the posited “disease” or condition for effective treatment planning, implementation, and assessment. Editor's note with author agreement.

³ The reader is asked to consider that the recent medicalizing and pathologizing of a range of human behaviors–noted as “disease mongering” in the Internet–include categories of substance use, misuse, abuse, addiction, dependency, habituation, hazardous drinking, etc., are at best a consensualizing labeling process, and not a diagnostic process. Such labeling is based upon the labelers’ criteria whose validity is not based upon empirical generalizability. “Alcoholism” and a range of “drug abuses,” before this term was created, and however defined, were associated for millennia with sin as their etiology. A usable diagnosis, based upon a process of gathering valid and relevant information and accurately interpreting and understanding such “data” (knowledge) in order to make a needed decision needs to supply a minimum of three types of information: etiology, process, and prognosis. A contemporary flaw in this process is associated, most generally, with the reported “explanation” about any type of substance misuse as being a unidimensional, linear either/or description which does not adequately distinguish between initial use or non-use, ongoing use or non-use, changes in use (patterns, manner of use, meanings, functions of use, sites of use, frequencies of use, etc.) cessation of use, beginning again which can result in our “knowing” without adequately understanding a phenomenon which is dynamic, nonlinear, complex, and not simply complicated, multi-dimensional, level-phase structured, and bounded (time, place, selected demographics, etc.) This is not a semantic issue. Editor's note with author agreement.

⁴ Treatment can be briefly and usefully defined as a unique, planned, goal-directed, temporally structured, multi-dimensional change process of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-, tradition-, mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used persons diagnosed with substance use disorders–of whatever types and heterogeneities–which aren't also used with non-substance users. This remains as an ongoing conceptual flaw. Whether or not a treatment technique is indicated or contraindicated, and its selection underpinnings (theory-, empirical-, principle of faith-, tradition-based, etc., continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and well-being treatment-driven models, there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success and failure as well as iatrogenic-related harms. Treatment is implemented in a range of environments; ambulatory as well as institution-based, and can include controlled environments. Treatment includes a spectrum of clinician–caregiver–patient relationship representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician–treatment agent make the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making, which facilitates collaboration between clinician and patient(s) in which both are active, and (3) the “informed model,” in which the patient makes the decision(s). Editor's note with author agreement.

Additional information

Notes on contributors

Madeline A. Naegle

Madeline A. Naegle, PhD, CNS-PMH, BC, FAAN, US, is professor, NYU College of Nursing, New York City, where she coordinates a specialty course sequence in substance related disorders for nurse practitioner students. She is assistance director, the Infectious Disease Core for the Center for Substance Abuse and HIV Research, and director of the WHO Collaborating Center for Geriatric Nursing. Prof. Naegle has implemented five Federal-funded grants to advance nursing curriculum and faculty development on prevention and care of persons with substance-related disorders. She is currently co-investigator of Project SARET (Substance Abuse Education and Training), a NIDA-funded inter-professional program to increase the number of nursing, medical, dentistry, and social work students seeking to engage in substance abuse research. Dr. Naegle is the founding editor of the Journal of Addictions Nursing and has published on impaired nursing practice, addictions education, and substance use in older adults. She serves on the Addictions Council for the American Psychiatric Nursing Association and chairs the psychiatric-mental health and substance abuse expert panel of the American Academy of Nursing. Dr. Naegle practices privately as a psychotherapist.