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Inpatient Nursing in Addiction

Care

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Disclosures

“Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to

disclose.”

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Assessment on Admission

Initial Nursing Assessment (INA) of admitted patients asked two sets of questions that could identify a patient with “at risk” substance use behaviors.

Effective November 4, 2014, Nurses Screening for Substance Use Disorders was established throughout MGH

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Assessments were done nearly 100%

of the time….but

• 50 % of nurses were not sure what to do once they screened the patient

• 25 % were not sure how to communicate the results of screening tool to patients

• 25 % were not comfortable with SUD subject matter

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Round table in-services

Informal discussions held to understand nurses’ attitudes, challenges and feelings about caring for patients with SUD.

• Nurses talked about feeling unprepared and their desire for

knowledge. • Discomfort about delving in to patients lives too deeply. • Identifying lack of privacy to do ask such questions double

rooms, family present etc. • Identifying biases. • Identifying personal experiences with their own family

members or friends as making such interactions challenging.

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Maladaptive

Behaviors

Understand that the patient population are experts on getting their needs met via:

Manipulation

Maladaptive coping skills

Intimidation

To care for this population, you need to: Set limits on behavior

Reflect back to patient…keep the patient the focus

Seek out support for yourself

Try not to get “sucked in” and engage in a struggle with the patient

Develop a plan of care to ensure staff consistency –

All staff need to be on the “same page”

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Behaviors That Made it Difficult to

Care for Patients

Hostage Holding

Staff Splitting

Manipulation of feelings

Lying

Verbal Abuse – name calling, intimidation, finding your weakness and pouncing on it…

Need for instant gratification

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Hostage Holding: “If you don’t get me more medication, I am leaving here AMA and if I die from an overdose, it is your fault!”

Staff Splitting: “You’re not doing your job, the doctor said I could have more medication if I needed it.”

Intervention: “I think it might be best if the three of us have a conservation so there will be no misunderstanding about your medication regime, as I have given you all the medications as ordered.”

Tip: Keep the focus on the patient & do not let it be about you

Behaviors That Make Care Difficult

and Possible Interventions

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Manipulation of feelings: “I thought nurses where supposed to help people, not hurt them, you are not helping me!”

Intervention: “I realize that drug withdrawal is very difficult and I have given you all the medication I can. Let me teach you some relaxation exercises that might help or you could take a warm shower.”

Manipulation of feelings: “You are an awful nurse, the nurse I had last night was so much nicer than you…she actually cared about me…”

Intervention: “I’m glad you had a good experience with your nurse last night, all of us here do our best to care for all patients.”

Tips: Don’t get sucked into an argument or defending yourself. These behaviors are likely an attempt to make you feel guilty so you will give into their requests

Behaviors That Make Care Difficult

and Possible Interventions Cont’d

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Verbal Abuse – name calling and intimidation: “You are totally incompetent…Get me another nurse, I am not dealing with you…”

“If you were a decent nurse, you would get me….I am filing a complaint against you…who is your boss!”

“Are you so stupid that you can’t see that I am withdrawing?”

Intervention: “Name calling is not acceptable and certainly not going to help the situation.” Try to reflect back on the patient and NOT take the comments personally… “I understand that you are uncomfortable…I can give you more medication in…

Tips: Patient’s do lie to get needs met…document very often and accurately Seek out support from colleagues, leadership

Behaviors That Make Care Difficult

and Possible Interventions Cont’d

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Engaging Nurses in Education

Collaboration of advanced practice nurses and nurse leaders from research, education and clinical practice (with full support of nursing leadership) established a six month training program.

30 nurses from inpatient units hospital wide were recruited to participate in an educational intervention related to SUD with the expectation of improving attitudes and passing the Certified Addictions Registered Nurse (CARN) exam.

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MGH Submission of Research Grant

for an Educational Intervention

Significance

• SUD treatment is complex and nurses have perceived educational needs in providing care for these patients

• Growing number of patients with SUD treated hospital-wide. Nurses feel distressed when caring for SUD patients

• Nurses recognize Compassion Fatigue (CF) impacts caring behaviors

• Studies show predictive relationship with caring, patient advocacy and satisfaction

• Quality of care for SUD patients improves when nurses understand Evidence Based Practice

• Magnet evidence incorporated into project

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Purpose of study/project:

• To provide education to a cohort of nurses about Substance Use Disorders (SUD) and Compassion Fatigue (CF).

• These nurses would be required to take the Certified Addictions Registered Nurse Exam(CARN) and pass rates will be examined.

• Additionally, pre and post data collection, comparing and contrasting data related to CF, patient safety, attitudes and stigma, and addressing patient outcomes by looking at quality and safety data will be compiled.

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Nurses’ knowledge about addictions

was measured by two mechanisms:

• 1) Nurses’ Knowledge of Addictions Questionnaire

• 2) Certified Addictions Registered Nurse Exam (CARN)

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Nurses’ Knowledge of Addictions

Nurses’ knowledge about addictions was measured

• At baseline and completion of the educational

• Using a questionnaire related to the definition of addiction, knowledge of various types of addictions and associated consequences.

• Initial cohort of participants completed the knowledge questionnaire at the beginning end of the program.

• Pre and post test comparison revealed substantial growth in knowledge about types of addiction

• And growth in knowledge about consequences of addictions, albeit smaller.

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The second measure of nurses’ knowledge of addictions was the pass rate on the CARN Exam

• 14 of the 17 nurses who have taken the CARN exam have passed and several more nurses plan to take the exam in 2017.

• The national CARN pass rate is 74%. At MGH, the pass rate is 82%!

Nurses’ Knowledge of Addictions

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Nurse Leadership Commitment

Albert H. Brown Visiting Scholar Program

• Each year, the Medical Nursing Division sponsors a medical visiting scholar day in support of nurses working in the medicine specialty.

• The day features visiting scholars presenting on a specific topic (clinical or non-clinical) of interest to nursing staff.

• A day full of narratives, panel discussions, keynote addresses

• 2016 recognized the overwhelming desire of nurses wanting more education about the Opioid Crisis, Substance Use

Disorders and the Care of these patients.

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Remember Your Role

• Advocate and care for individuals of all backgrounds and support them through health and illness--No one chooses to be addicted... but Nurses make a choice to care.

• Be attentive--Patients feel helpless, when it seems no one is listening. Be aware of what your actions and say and watch closely for the patient’s non-verbal cues. If you discuss your plans for the patient and make adjustments based on feedback, you will establish trust.

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Toward a Model of Empathy and

Acceptance

• Caring for patients with Substance Use Disorders (SUD) is complex due to “clinical challenges and personal risk that nurses often feel unqualified to address.” (Ford, 2011

• What helps? Educate in an “open climate,” address attitudes that stigmatize, provide and utilize resources, and support acquisition of skills and knowledge to enhance care.

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Withdraw/Time Out: staff withdraws and returns later, can help at impasses and enables staff to compose themselves.

Contingency Contracting: tell the patient what they need to do and what and when they will get as a result.

CAUTION: Do NOT make promises that you can not keep!

Toward a Model of Empathy and

Acceptance

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Stay Out of the Struggle

• Avoid belittling or provoking the patient

• This can be consciously or unconsciously

• You don’t need to respond to every comment

• Be careful not to become defensive

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CASE STUDY: September 2015

56 y/o man with a history of poly-substance use

disorder

CC: Presented with worsening ascites, dyspnea and mental status changes, brought in

by his ex-wife.

HPI: Mr J -noticed slow progressive health decline for past year. Reported challenges getting to and from outpatient appointments. Was living on a second floor walk up, became increasingly difficult to climb stairs w/ SOB fatigue and generalized weakness, eventually inability to do ADL's.

His weight had steadily increased, widening abdominal girth and lower extremity edema.

His wife who lives next door also noticed the change in his appearance and eventually when his symptoms progressed to the point he could no longer function he came in to the hospital. He was quite ill at the time of admission.

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Past Medical History

• Cirrhosis • Hepatic encephalopathy • HTN • Hepatitis C Virus, • Two prior bouts of endocarditis w/2l

lengthy hospitalizations • Alcohol withdrawal Seizures. • Intubations and ICU stays. • Anasarca • Acute kidney injury • MRSA bacteremia • Anemia • Pain of right lower extremity • ETOH abuse • Disseminated intravascular

coagulation

• Opioid dependence • Viral hepatitis C • Gastroesophageal reflux disease • Depressive disorder • Insomnia • Alcohol dependence • Peripheral edema • Metabolic acidosis • Hepatic encephalopathy • Pancytopenia • Cirrhosis • Intravenous drug user • Mixed acid-base

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Medication List

• Acamprosate 666 MG PO TID • Buprenorphine

2mg/Naloxone 0.5mg 2 TAB PO BID

• Ciprofloxacin 500 MG PO QD • Folic Acid 1 MGOmeprazole 20

MG PO QD • PO QD • Lactulose 30 ML PO QID • Melatonin 5 MG PO QHS • Multivitamins 1 CAPSULE PO

QD • Naloxone Hcl Unknown ETT

• Propranolol Hcl 20 MG PO BID • Rifaximin • Spironolactone 100 MG PO QD • Thiamine Hcl 100 MG PO QD • Torsemide 60 MG PO QD

No Known Drug or other

Allergies

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Substance Use History

• After a year of abstinence/recovery in hopes of getting listed for transplant, he relapsed when he was told

he would not be listed. • Was drinking 1/2 pt vodka every few days during the month of August 2015 and was using IV heroin

sporadically, he had stopped going to suboxone clinic through PCP.

• First used IV heroin at age 17, developed alcohol problem around the same time. At his highest level of alcohol use he was drinking approximately 1 to 2 liters of liquor daily. MJ, used cocaine sporadically.

• On suboxone from early 2014 to the summer of 2015, when he got off track • He has never taken methadone • Chart review revealed he was prescribed acamprosate by his PCP, but he did not recall ever taking this. • Vivitrol had been recommended for him but he declined at the time ("I wasn't ready") and he opted for

suboxone. • He had attended Intensive Outpatient Programs programs three times • He had been to severeal detoxes • Longest stretch of sobriety, was 5 + years in the 1980s when he was incarcerated. • During that time he found groups to be particularly helpful. He attends meetings and has a sponsor in

recovery • Smokes cigarettes, but has cut down from over a ppd to 5 or 6 cigs daily and continues to reduce

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Social and Family

• Lives alone in an apartment just south of Boston.

• Separated from wife Rita who lives next door, they are still friendly and watch out for each other but they are not together as a couple.

• Drug use was a major stressor in their relationship - she quit IV heroin 10 years ago cold turkey, and he was unable to do the same, which led to their split.

• He is on disability

• His mother who is 82 and healthy comes to see him regularly, brings him food etc.

• Hypertension Mother

• Breast cancer Mother

• Diabetes type II Father (deceased)

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Psychiatric History

Insomnia Diagnoses: Major Depressive Disorder, never been on medications Past hospitalizations: none No current mental health treaters/providers. Prior treatment: therapy at Faulkner, positive experience; IOP for addiction Suicide attempts: none Violence: none

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Legal History

• Has been incarcerated in the past. Has an open case for going into someone's unlocked car when it was cold out in the winter. He is willing for us to talk with his lawyer to have a court date moved so that he can get treatment.

Legal

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OLD WAY…Moral Model

• Moral failing

• Weak-willed

• Character flaw

• Spiritual deficit

• Conscious choice

• Bad person

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Nursing Note

56M PMH ESLD 2/2 HCV, EtOH (MELD 33), alcohol and opiate dependence, currently on subutex, who desires to discontinue buprenorphine

• Mr W. has been in recovery without alcohol or heroin use for past 9 months,

• He has shown his commitment to recovery through active participation with both medical therapy (buprenoprhine, acamprosate) and behavioral health participation.

• He remains highly motivated to abstain from alcohol and opiates.

• He needs an outpatient buprenorphine provider

• He understands the risk for relapse and accepted counseling on these risks.

• He is willing to participate in Bridge clinic until one is found.

• His greatest desire and goal is gaining eligibility for liver transplant.

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Transplant Success!

• May 2016

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Pass Off Notes:

May 2016, from the ACT covering MD

• Long history of OUD who we have been following since about September, and has been stable on Suboxone.

• He has ESLD and as of last week was just put on transplant list. He has been having ongoing problems with BLE swelling and volume overload. Mental status has been a bit murky last week, but always pleasant.

• SW is following with check ins.

• Team/CM was considering possibility of stopping Suboxone to get him into medical rehab. I asked them to not do that and to consider one of the few rehabs that would. Patient refused transfer to one local hospital, (which is probably wise).

• At this time awaiting liver versus returning to SNF/rehab.

• Maintain Suboxone, with decrease dosing d/t MS