Nurses regularly encounter individuals with substance use disorders (SUDs). Whether a SUD is the primary focus of care or not, understanding how best to work with individuals who have SUDs is important. There are several reasons why nurses, irrespective of their work setting, need to understand how to effectively approach their work with those experiencing SUD, as well as provide interventions. This article describes a study conducted by the first author, examining knowledge about how addiction specialist nurses work with those with SUDs, as well as caring interventions to employ. The interventions may inform non-addiction nurses how best to work with people with SUDs.
First, nurses should understand how to effectively work with individuals with SUD because of stigma. Studies have revealed that healthcare providers, including nurses, hold stigmatising views towards those with SUD (Russell et al, 2017). Even when staff believe that the views of individuals with SUD are being valued, those individuals themselves may feel misunderstood (Larsen and Sagvaag, 2018). When people feel stigmatised, they may avoid or delay healthcare treatment, thereby exacerbating pre-existing conditions (Mundy, 2012). The root of stigmatisation may be moralising beliefs about substance use (Chang and Yang, 2013), rather than understanding the biological components of addiction (Heilig et al, 2021).
A second rationale for nurses to learn how to best work with individuals with SUD is because of the prevalence of SUD. Addictions are very common worldwide. Approximately 269 million individuals used illicit drugs across the globe in 2021 (United Nations Office on Drugs and Crime, 2023). According to the World Health Organization (WHO), cannabis is the most used substance worldwide (WHO, 2024), however, opioids are more dangerous and resulted in 125 000 deaths in 2019 (WHO, 2023).
Furthermore, the costs incurred by society because of SUDs are significant. These disorders may result in family problems, financial issues, loss of productivity, domestic violence, and crime. Economically, it has been estimated that alcohol and drug use has resulted in yearly costs of over $600 billion in the USA (National Institute on Drug Abuse, 2018).
Methods
This study was conducted between January 2021 and September 2021 by the first author, as part of the requirements of his Master of Nursing Program. The main purpose of this study was to examine effective nursing interventions. The research question was: ‘What actions, behaviours, and interventions in inpatient settings used by nurses promoted the recovery of individuals with SUD within a Canadian academic, teaching, psychiatric hospital?’
Study design
Within this study, qualitative description (QD) was used as the methodology. QD researchers seek to describe a population's perceptions of a phenomenon of interest, which may include events, situations, or behaviours that can influence a population (Bradshaw et al, 2017). This study was conducted in a central province of Canada, within a teaching psychiatric hospital. Participants were recruited through purposeful sampling via email. Inclusion criteria included: age 18 to 64 years; must be a practising registered practical nurse (RPN) or registered nurse (RN); and must have provided care to individuals with SUD. Exclusion criteria included being a health professional other than a registered nurse and having not provided care for individuals with SUD.
Data collection and analysis
Because of the COVID-19 pandemic and social distancing, data were collected virtually (through Webex) using semi-structured interviews. Interviews were 1 hour in length and were audio-recorded for transcription purposes. See Box 1 for interview questions. NVivo12 software was used to assist data analysis. Ethical approval from the university research ethics board, as well as from the teaching hospital, was sought and received, and consent forms signed.
Interview questions
Demographics of participants
Four participants between the ages of 23 and 39 took part in the study (Table 1). There were two male participants, one female participant, and one non-binary participant. Three participants had their RN licence, and one was an RPN who was completing their Bachelor of Nursing degree. Three participants worked in addiction-specific inpatient units and one worked in a general psychiatric inpatient unit. Two of the three RNs had their Canadian Nurses' Association psychiatric certification. Participants had between 3 and 9 years of experience working with individuals with SUD.
| Participant 1 | Participant 2 | Participant 3 | Participant 4 | |
|---|---|---|---|---|
| Age | 28 | 39 | 23 | 34 |
| Gender | Male | Female | Male | Non-binary |
| RN or RPN | RN | RN | RPN | RN |
| CNA psychiatric certification | Yes | None | None | CNA certification |
| Workplace (addiction specific or general psychiatry) | Addiction specific | Addiction specific | Addiction specific | General psychiatry |
| Length of time working with ISUD | 5 years | 9 years | 3 years | 4 years |
| Additional education | Addiction courses |
Motivational interviewing | Psychiatric certifications | Motivational interviewing |
CNA=Canadian Nurses' Association; ISUD=individuals with substance use disorder; RN=registered nurse; RPN=registered practical nurse
Findings: effective nursing interventions
Effective nursing interventions were the main focus of this study, including philosophy of care. The following themes emerged: person-centred care, empowering the person in their recovery journey and fostering hope, and employing a holistic approach.
Person-centred care
Person-centred care involved the following effective practices: establishing a therapeutic relationship and co-creation of a plan. An essential component in the beginning of the inpatient stay is to establish a relationship with the individual receiving care. This is fundamental for further interventions to occur, otherwise the inpatient stay may be hampered.
‘I think what really helped is first, establishing relationship with the client. And once you establish relationship with the client, you eventually get to have a meaningful discussion with the client. Some of the clients may even engage and talk to you about their past history, their addiction, the substance, how much they are taking.’
Nursing interventions that enhance the therapeutic relationship include being welcoming, friendly, being available, using empathy, adopting a non-judgemental attitude, acknowledging and applauding the person's decision to come into treatment, and validating hardships that have occurred in the person's past. These approaches can help to lessen the power imbalance within the nurse–person therapeutic relationship. Nurses can use communication skills such as open-ended questions, probing questions (Participant 4), answering questions, and inviting reflection and verbalisation of individuals' experiences (Participants 1 and 3). Conversations can include gentle persuasion about making healthier choices.
‘I think meeting people where they are, you know providing the support (to) make some healthy choices, little bit safer, and kind of use that gentle persuasion, maybe planting seed of abstinence later on – that's probably more effective than cold turkey …’
Timing of conversations is important. Individuals may have varying mental or emotional states when they arrive at the inpatient unit, based on potential intoxication or withdrawal states. Although nurses may need to conduct specific assessments, they must gauge if the person is ready to converse and delay assessments/interventions as needed (Participants 2, 3, 4).
‘This is the first time they're coming off opioids … during that time, you don't want to do goal setting until they feel a bit better.’
A lack of trust may also impact conversations with care providers. Individuals may also not trust the healthcare system.
‘I'll tell them, if they're guarded, you know, I am here if you want to talk but if you don't want to talk, that's okay too. I find that … occasionally will break down that barrier. Well, okay, now there's no pressure.’
All participants discussed how vital it is to focus on the goals of the person receiving care – the co-creation of a plan. All participants outlined that it is imperative to set out a plan for the admission. Nurses can purposefully ask about the substance(s) of concern, including the type of substance consumed and the amount, and context for the admission (Participants 1 and 2). Nurses can seek to understand what recovery means for individuals with SUD, what their goals are (Participants 2, 3, 4), and what they would like to achieve before discharge (Participants 3 and 4). Cessation or reduction of substance use can also introduce issues that individuals with SUD may have challenges with. For example, they may have cravings to use substances after admission. They may not know how to increase their coping skills. Participants outlined that nurses could discuss future possible situations and highlight some helpful goals (Participants 1, 3, 4).
Empowering individuals and fostering hope
All participants discussed that effective interventions were focused on empowering individuals with SUD and fostering hope. Subthemes that recurred were education, ensuring that individuals have options and choice, and providing encouragement and advocating on their behalf.
Individuals with SUD may feel disempowered by the challenges they have faced. They may feel unable to achieve their goals and therefore continue with their substance use. All participants found that it was helpful to increase the individuals' belief in themselves to achieve goals.
‘The decision to stop using substances is huge … they don't know a life without it, so it's really scary … and it's brave and acknowledging that gives them some self-esteem … and that they can change.’
Education can focus on substances, their impact, and potential interventions. Nurses can provide education on the withdrawal process (Participants 2, 3, 4) and potential pharmacotherapy that can be used to alleviate withdrawal symptoms (Participant 2). Another education focus can be on harm reduction and discussing risks of hepatitis C and HIV with intravenous drug use (Participant 1), the safe use of needles, interventions for when an overdose occurs, the use of a naloxone kit, the law (in Canada, the Good Samaritan Overdose Act), and the use of a safe consumption site (all participants).
After the person's goals have been identified, Participants 2, 3, and 4 outlined that individuals with SUD should be made aware of options. This can help those individuals who are unsure of their next steps (Participants 2 and 3). A discussion on the positive impacts of each option and potential outcomes of that option are important.
‘I try to get people to walk through the choices of the options available to them and what would happen with each. Because I find that a lot of people don't think that through …. if you made this choice, what's the best-case scenario of what would happen? What's the worst-case scenario …?’
All participants discussed that after option identification, individuals should be given the choice regarding what they would like to do. Nurses can clarify their preferences if there are inconsistencies with the proposed care plan (Participants 1 and 2). By providing choice, individuals can learn that treatment will not be forced on them (Participants 2 and 3).
Individuals with SUD need to have hope that they can attain their goals and have a future. Encouragement/advocacy included exploring what the individual would like in life and discussing positive aspects of their life (Participants 1, 2, 3). Speaking about social supports such as their partner, children, and friends who care about them can help increase hope (Participant 3). Asking about future plans and how they envision their life without substances can also be beneficial (Participants 1, 2, 3). Thus, individuals refocus on their goals, start thinking about their next moves, and identify skills they possess or require to address their challenges (Participant 3).
To empower individuals with SUD, all participants highlighted the need to advocate. Advocacy focuses on nurses promoting the person's best interest (Participants 2, 3). Issues to advocate for include: a person's safety, change of room if there are problems involving others in the unit (Participant 3), or the need for a longer admission (Participant 2).
Employing a holistic approach
The final theme was employing a holistic approach. Sub-themes included: biological, psychological, and social facets.
Although nurses are well acquainted with how to address biological issues, individuals may have issues related to pain, complicated by SUD. Nurses may need to respond to medical issues such as overdoses. Depending on nurses' location of work, an ambulance may be called (if in the community), a ‘code blue’ may be called, and naloxone may be administered. All participants highlighted that withdrawal symptoms need to be managed. If withdrawal symptoms are not addressed, individuals with SUD may have increased cravings to use substances (Participant 1) and may abruptly leave the hospital (Participant 3). Education about withdrawal symptoms may be necessary for those seeking treatment for the first time and teaching about the use of pharmacotherapy to manage withdrawal symptoms. After symptoms are assessed, medications are offered to the individual with SUD. However, Participants 2 and 3 also spoke about being mindful of the effects of the medication used for withdrawal management. Medications may cause sedation or euphoria that the person may still be seeking. Being aware of the person's overall presentation and using clinical judgement to curtail further medications can be warranted (Participant 2). Participants also discussed the use of non-pharmacotherapy interventions to handle withdrawal: ginger ale and crackers for nausea (Participant 2) and hot packs to manage pain and muscle aches (Participant 3).
To support individuals with SUD psychologically, nurses assist with co-occurring mental health issues and on providing tools that individuals can use after the admission (all participants). Despite trying to address mental health issues, individuals may experience a crisis. When individuals with SUD begin to have increased emotional distress, nurses dedicate time to provide emotional support, engage in therapeutic communication, participate in safety planning, encourage the use of coping skills, and provide medications as needed (Participants 2 and 3). For those with few coping skills, participants noted the importance of supporting individuals to gain such skills. The focus should be on supporting individuals with SUD to independently manage triggers and cravings (Participant 4).
It is important for nurses to focus on the support network of individuals with SUD (Participants 1, 2, 3). Assessment focuses on current support, especially on discharge (Participant 2). If supporters are identified, such as family members, they can be encouraged to participate in care discussions (Participant 2). For those who have difficulty with identifying support, connection with formal, community, and peer support networks is vital. Nurses can boost social skills that individuals may have struggled with (Participant 2). They enforce rules, set boundaries, and practise interpersonal communication such as saying ‘no’(Participants 2 and 4). Individuals can be referred to peer-led groups such as Alcoholics Anonymous (AA) and other self-help groups (Participant 1).
Discussion
This study highlighted effective nursing interventions when working with individuals with SUD. Participants identified that an effective guiding approach when caring for these individuals is being person-centred. A scoping review by Marchand et al (2019) identified the establishment of a therapeutic relationship by using empathy and being nonjudgmental, shared decision-making, and individualising holistic care as fundamental to person-centred care for individuals with SUD, validating the importance of interventions outlined in the study for addiction nursing care. The use of person-centred-care enhances patient engagement, allows for a tailored plan, improves trust and the therapeutic relationship, reduces stigma and judgement, enhances autonomy and empowers individuals with SUD, ultimately improving nursing care and outcomes (Prochaska and DiClemente, 1983; National Institute for Health and Care Excellence, 2014; WHO, 2016; McCormack and McCance, 2017; Substance Abuse and Mental Health Services Administration, 2019).
Interestingly, participants discussed how promoting harm reduction is an essential intervention in the recovery of individuals with SUD. Harm reduction allows for a flexible approach that encompasses many holistic interventions supporting individuals with SUD (Danda, 2012), augmenting a person-centred approach adopted by nurses. Participants highlighted that nursing interventions rooted in harm reduction were those that support individually identified goals including continued substance use and providing education related to ways to reduce harm if substance use continues. It is vital that nurses support the goals that the individual would like to achieve and not promote a specific goal that contradicts the individual's identified goal (Bartlett et al, 2013). Additionally, harm reduction supports nurses in maintaining a therapeutic relationship with individuals with SUD and continuing to provide support and interventions throughout their recovery journey However, supporting the choices of those with SUD may not work in all settings. For instance, individuals within the forensic mental health system may have a specific order to abstain from alcohol or drug use within their disposition (Bettridge and Barbaree, 2008). Nurses practising in such settings may have a different and challenging therapeutic relationship when working with individuals with SUD. Thus, harm reduction may not always be applicable within all psychiatric settings and can be difficult to employ.
The study illuminates some interventions such as spirituality and culture that are infrequently mentioned or used by nurses. Only one participant raised the importance of discussing spirituality and culture in working with individuals with SUD. Nurses may underestimate the importance of spirituality in the recovery of individuals (McDowell et al, 1996). Yet, spirituality may be beneficial as it fosters hope, reassures individuals that life will improve, and improves the persons' state of mind (Grim and Grim, 2019). In terms of culture, it has been identified that African, Caribbean, and Black Canadians have challenges with substance use (Nguemo et al, 2019) such as cannabis use (Tuck et al, 2017). In addition, on-reserve First Nations youth have a higher prevalence of alcohol (Lemstra et al, 2013) and opioid abuse (Health Canada, 2011) when compared with other youth. Although such problems exist, a notable barrier is a lack of culturally relevant and appropriate services (Gainsbury, 2017), despite culture being a protective factor that fosters resilience (Henson et al, 2017). Perhaps the lack of mentioning interventions rooted in spirituality or culture can be explained by having too broad, general questions on the interview schedule as the purpose was to cover as many effective interventions as possible that nurses used to promote recovery; the questions did not focus on any specific intervention. As such, how nurses make use of interventions rooted in spirituality and culture when working with individuals with SUD should be further explored.
Implications for nurses
Knowledge about effective nursing interventions acquired from this study may improve the care of individuals with SUD. Nurses working in a variety of settings may adopt some of these interventions to help individuals. However, they may also be appropriate in some situations with people who do not experience SUD.
Limitations
A limitation of the study is that the sample size is small, with only four participants. Due to the smaller sample size, there could have been interventions that were not discussed and this limits transferability. Future studies should consider increasing the sample size or reconducting the study at the same site to provide longitudinal data. Furthermore, the study highlighted the perspective of nurses, and individuals with SUD may have different perceptions; that is, the interventions nurses may believe are effective may not be viewed as effective by the individuals themselves. Finally, the interview tool contained questions that may have been too broad, which may have resulted in the omission of interventions such as those focused on spirituality and culture.
Conclusion
Effective nursing interventions when working with individuals with SUD were explored in this study. These were rooted in the themes of being person-centred, empowerment and fostering hope, and holistic care. Although the study offered such effective interventions, nurses should be mindful that these interventions will not fit all individuals or situations; person-centered care is necessary. This study counters such unfortunate stigmatising experiences that individuals with SUD continue to face, there are additional organisational, systemic, and national strategies that could be implemented to improve the care and experiences of these individuals.