Marianne T. Marcus, EdD, RN, FAAN, Christine Savage, PhD, RN, CARN, FAAN, and Deborah S. Finnell, DNS, PHMHNP-BC, CARN-AP, FAAN
CHAPTER OUTLINE
■ HISTORY OF DEVELOPMENT OF NURSING ROLES IN ADDICTION CARE
■ CURRENT TRENDS IN SUBSTANCE USE
■ LEVELS OF NURSING EDUCATION AND PRACTICE
■ GENERALIST'S ROLES RELATED TO ADDICTIONS
■ THE ADDICTION NURSE
■ ADDICTION NURSING WORKFORCE
Nurses comprise the largest segment of the health care workforce with 3.1 million registered nurses (RNs) in the United States, 85% of whom are employed in nursing (1). Moreover, nurses are typically the first point of contact for patients entering diverse health care environments and likely to have sustained close contact with patients and families. The American Nurses Association defines nursing as the “protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (2). This broad definition supports a comprehensive role in prevention, detection, and treatment of health problems, competencies that are critical for addressing the health challenges associated with substance use and addictive disorders. Nurses are prepared to be patient educators who support and encourage behavior change to improve health. Professional characteristics such as sustained patient contact and preparation as educators support a mandate for a comprehensive nursing role in addressing substance use and addictive disorders at all levels of practice and in all health care settings (3). This chapter examines levels of nursing education and practice and the various roles nurses have as generalists and advanced practitioners with a particular focus on addiction nursing. Practice competencies, standards, certification requirements, and the professional organization that supports and governs the nursing role in addressing addiction will be explicated.
HISTORY OF DEVELOPMENT OF NURSING ROLES IN ADDICTION CARE
Content on alcoholism and recommended nursing care of late-stage alcohol dependence first appeared in nursing textbooks in the 1950s (4). Federal funding increased nursing education for this important area of practice beginning in the 1970s. In 1972, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded alcoholism nursing traineeships for undergraduate and graduate students at the University of Washington (5). Estes and Heinemann (6) published a definitive nursing text on alcoholism in 1977, again, addressing alcohol addiction with sections on diagnosis, alcohol consequences on body systems, alcohol problems in special populations, and interventions.
Despite these national efforts, translation of content related to the prevention and treatment of substance use disorders into nursing curricula did not occur across schools of nursing and, when included, only minimally. An early national survey of substance use in nursing curricula revealed that content was confined to care of patients with substance use disorders and was taught mainly in psychiatric mental health courses (7). From these early beginnings, the nursing profession has made progress toward setting practice standards related to substance use disorders (8). Parallel to the setting of standards for practice has been the building of this content into nursing curricula that have included developing faculty expertise(9,10), assessing curricula (7,11,12), designing specific curricula (13–17), offering continuing education (18), and participating in interdisciplinary faculty development initiatives (9,19–21). Disciplinary and interdisciplinary faculty development initiatives promoted expertise and enhanced curricula related to the full spectrum of substance use, including prevention, detection, and treatment, a shift from the focus primarily on treatment of addictive disorders. This focus on the entire continuum of substance use is consistent with mounting evidence of the importance of prevention and early intervention emphasized by the World Health Organization (WHO), which identified alcohol as the third leading cause of preventable death globally (22). The NIAAA also promotes this wider view for addressing alcohol use with the publication of practice guides for clinicians (23).
Thus, the global focus of addiction care has shifted to a broader upstream approach aimed at reducing harm through prevention of at-risk substance use and early intervention for those at risk for developing substance use disorders, decriminalization of substance use, and broader policy initiatives (24–26). This expanded view has required that nurses at all levels of practice broaden their skill set from treatment of substance use disorders to include screening for substance use and further assessment when that use increases the risk for adverse health outcomes. Unfortunately, recent surveys of substance use in nursing curricula do not reflect this shift to a broader approach to the problem of substance use disorders. Mollica et al. (27) found little change in alcohol curricular content from studies conducted more than 20 years ago. Survey questions in most of the recent studies (27–29) continue to reflect the narrow downstream focus on alcohol dependence and treatment. Therefore, such studies would be unlikely to capture information about substance use across the life span, prevention strategies, and screening for at-risk use. Savage et al. (30) conducted a national study of curricula in baccalaureate schools of nursing using questions that reflected the broader scope of alcohol-related content, an essential content as determined by an expert panel convened by the NIAAA (31). This comprehensive survey included content on genetics, neurobiology of alcohol addiction, prevention of alcohol use disorders, screening and brief intervention (BI) for at-risk alcohol use and alcohol disorders, withdrawal management, treatment for alcohol use disorders, alcohol-related health consequences, and legal/ethical issues. Questions were designed to capture these content areas in courses that addressed the life span and domains of nursing practice. Comparison of findings from this study with the seminal 1987 study by Hoffman and Heinemann revealed little progress over the last 24 years. Sixty-nine percent of the schools in the new study reported 10 or less alcohol-related content hours in the curriculum compared to 67% in the original study. Most of the content still resided in the psychiatric/mental health courses, indicating that other important areas are not addressed.
CURRENT TRENDS IN SUBSTANCE USE
Emerging trends in at-risk substance use have serious implications for nursing practice, underlining the importance of developing a nursing workforce with the knowledge and skills to actively participate in the prevention of adverse consequences related to at-risk use as well as treatment of those with a substance use disorder. There is increased recognition of and focus on the global burden of substance use. For example, alcohol is a risk factor for 60 types of diseases and injuries (32). Over 50% of all adults report current alcohol use, and almost a fifth of adults 18 years of age or older are current tobacco users (33). Alcohol and tobacco use are among the top three causes of preventable death (34). Of concern is the dramatic increase in substance use levels among older adults. The Substance Abuse and Mental Health Services Administration (SAMHSA) projects the need for substance abuse treatment among Americans over age 50 to double by 2020. The most recent National Survey on Drug Use and Health shows that about 4.3 million adults aged 50 or older used an illicit drug in the past year. While marijuana was more common among men in that age group, among those aged 65 and older, nonmedical use of prescription drugs was more common than marijuana (35).
Another trend is prescription drug abuse, identified by the Centers for Disease Control as an epidemic. Youth are a particularly vulnerable population given that nearly one-third of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription drug nonmedically (36). Addressing the prescription drug epidemic is a top priority for public health. The Office of National Drug Control Policy is urging the education of parents, youth, and patients about the dangers of abusing prescription drugs combined with education on the appropriate and safe use and proper storage and disposal of prescription drugs. Nurses and addiction nurses, in particular, can contribute to this action in developing and providing education to at-risk patients and populations.
Effective reduction in the burden of disease associated with substance use requires the ability to screen for substance use disorders across the life span and conduct further assessment related to the amount and pattern of substance use as well as any consequences associated with the use of alcohol, tobacco, and other drugs. The comprehensive nursing role in addressing the full continuum of substance use is evolving as the field is advancing. To keep pace, nurses need to have requisite knowledge and skills to provide evidenced-based interventions across the continuum of use and the life span and demonstrate competencies appropriate for all levels of practice and all practice settings.
LEVELS OF NURSING EDUCATION AND PRACTICE
In 2008, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) engaged in an initiative to assess and recommend changes in the nursing profession. Data gathered for the IOM report revealed the following information about nursing education and practice (37). Most nurses are RNs who receive an associate degree (ADN) in a 2-year program at a community college or a baccalaureate degree (BSN) in a 4-year university. Graduates of both levels of nursing education are required to pass the same nationally standardized licensing examination in the state where they intend to practice. Nurses with ADN preparation typically provide direct patient care in various health care settings. BSN nursing education includes additional preparation in leadership, research utilization, and population health. Master's degrees in nursing (MSN) prepare nurses for administration, clinical leadership, faculty positions, or advanced practice in a specialty area. Advanced practice registered nurse (APRN) roles include the nurse practitioner (NP), the clinical nurse specialist (CNS), the certified nurse anesthetist (CRNA), and the certified nurse midwife (CNM).
The NP is prepared to obtain histories and conduct physicals, diagnose and treat illnesses, prescribe medications, order and interpret x-rays and lab tests, and provide patient education and counseling (37). Scope of practice for NPs is regulated by individual states, and there is a wide variation in limitations imposed by the states. At present, 16 states and the District of Columbia permit NPs to practice independently (38). That is, the NP can diagnose, treat, and prescribe medications without a physician's supervision or collaboration (37). NP education and certification standards, recognized by most states, support this broad scope of practice, but regulations are more restrictive in the majority of states (37). The CNS gives advanced care in hospitals and other clinical sites, develops quality improvement programs, and serves as educator and consultant. CRNAs administer anesthesia in a variety of settings. It is estimated that CRNAs deliver more than 65% of all anesthetics in the United States. CNMs provide primary care to women including gynecology, family planning, prenatal care, low-risk labor and delivery, and neonatal care (37).
Doctoral programs in nursing fall into two principal types: research focused and practice focused. Most research-focused programs grant the doctor of philosophy degree (PhD), while a small percentage offer the doctor of nursing science degree (DNS, DSN, or DNSc) (39). These doctorally prepared nurses develop the science, steward the profession, educate the next generation of nurses, define its uniqueness, and maintain its professional integrity (39). The practice-focused doctoral degree is the doctor of nursing practice (DNP), which builds upon generalist education acquired through a baccalaureate or advanced generalist master's in nursing. DNP graduates are prepared for advanced practice roles and leadership in clinical settings. Common specialty areas within nursing include critical care, public health, home health/hospice, employee health, oncology, perioperative, rehabilitation, mental health, and school nursing (37). The IOM report, The Future of Nursing: Leading Change, Advancing Health (37), also sets forth recommendations to prepare the nursing profession to be a part of the transformation of the health care system. The report formulated the following key messages:
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education.
3. Nurses should be full partners, with physicians and other health professional, in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.
The IOM report has profoundly impacted all levels of the profession. Nurse educators are seeking to accommodate seamless academic progression to higher levels of education, and nursing groups advocate for broader scope of practice regulations for NPs. The lack of sufficient education in past and present nursing curricula means that the current and future nursing workforce is not fully equipped to address the nation's substance abuse crises. Nurses specializing in substance use and addictive disorders are critically needed to lead change and advance the health of individuals, families, and populations affected by alcohol, tobacco, and other drugs as well as maladaptive behaviors that may lead to addictive disorders.
GENERALIST'S ROLES RELATED TO ADDICTIONS
Considering the pervasive nature of at-risk substance use and substance use disorders and the associated serious health consequences, it is imperative that nurses at all educational levels have basic competencies to address this phenomenon (40). Core competencies for the generalist nurse graduate related to substance use were last identified in 2002 as a component of discipline-specific recommendations outlined in the Strategic Plan for Interdisciplinary Faculty Development (41). The Strategic Plan was a product of a 5-year collaborative agreement between the Health Resources and Services Administration (HRSA) and the Association for Medical Education and Research in Substance Abuse (AMERSA) in collaboration with the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA). The Strategic Plan was created to inform the federal government and others how to improve substance abuse education for generalist health professionals (41). The document was also used as part of a national initiative to train interdisciplinary faculty to enhance the curricula of their respective disciplines to prepare their students to meet the challenge of substance use (41). The disciplines included allied health, medicine, social work, nursing, pharmacy, public health, psychology, physician assistants, and dentistry. Competencies were recommended for each discipline by a panel of experts.
The core competencies as outlined by Naegle (4) for the generalist nurse can be broadened across levels of practice and grouped under stages of the nursing process. The nursing process is the basic sequence of steps used to define nursing care. Stages of the nursing process include assessment, or data collection; nursing diagnosis; desired measurable outcomes; nursing interventions; and evaluation. Table 32-1 depicts core competencies considered minimum knowledge and skills for generalist nurses educated at basic and graduate levels for each stage of the nursing process as they relate to prevention and treatment of substance use disorders. Two competencies also address personal attitudes and values related to substance use.
TABLE 32-1 GENERALIST NURSING COMPETENCIES RELATED TO ADDICTIONS
Adapted from Naegle MA. Nursing education in the prevention and treatment of SUD. Subst Abuse 2002;23(Supp 1):247–261.
Since the development of these competencies in 2002, significant changes in the field of substance use have emerged and have impacted nursing. In addition to the emerging trends previously discussed, evidence-based treatments including pharmacotherapy are available. While advanced practice nurses may not prescribe buprenorphine for the treatment of opioid addiction, nurses have a key role in partnership with the physicians who are qualified to prescribe this medication. Nursing care includes conducting screening, assessment, treatment monitoring, counseling, and supporting services and promoting relapse prevention skills (42). The vital nature of these nursing activities is highlighted in the description of a collaborative care office-based opioid treatment program wherein the nurse program coordinator and RN case managers provided care along the continuum. In this model, nurses demonstrated that they reduced the physician burden through communicating and collaborating with prescribing physicians, addiction counselors, and pharmacists (43). The value-added role of the nurse was identified in another model of care integrating buprenorphine treatment into HIV care with the point that “a nurse in the coordinator position gave the role and the service the credibility, from the perspective of both patients and other providers” (44). Thus, nurses can effectively provide high-quality care to the full extent of their license and within the federal regulations for buprenorphine treatment.
Advances in neuroscience have informed the understanding of substance use disorders and addictive disorders as brain-based disorders, shifting from a moral view to a science-based perspective. This paradigm shift can help diminish the blame and shame that is the stigma associated with addictions and hopefully remove barriers to available lifesaving treatments. With sufficient knowledge and competence, nurses can (a) identify those at risk, (b) conduct further assessment, and based on the assessment, (c) provide evidence-based interventions and, if within their scope of practice, prescribe evidence-based medications to support abstinence and recovery, and (d) ensure continuing care through referral to treatment (RT) for those needing specialty treatment. Additionally, nurses across all settings and specialties can teach patients and colleagues alike about the biologic mechanisms underlying substance use and how behavioral and pharmacologic treatments promote abstinence and recovery. Finally, the shift in the global focus from treatment of substance use disorders to a focus on reducing harm related to the continuum of use changes how nursing approaches competencies and the leveling of those competencies across levels of practice. The stated competencies are broad categories of requisite knowledge and skills for generalist practice, which should be continually updated to reflect emerging evidence in the field.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an example of a set of practice strategies that should be provided by all generalist nurses. Screening determines the extent of the substance use and signals the need for additional assessment and interventions as indicated. BI is a nonconfrontational, patient-centered approach to addressing unhealthy alcohol and tobacco use and illicit drug use. BI is intended to raise awareness of the consequences related to the substance use and motivate a patient toward behavior change (i.e., reduction in or cession of use). RT provides those patients who need more extensive substance-related treatment with referral to specialty care. An evidenced-based practice for detecting risk, as well as addictive disorders, and initiating appropriate clinician response, SBIRT, has emerged as a valuable tool. SBIRT has been shown to be effective in primary care patients with nondependent alcohol use (45) but to have limited effectiveness for drug use (46). Studies of SBIRT in emergency departments have found short-term effectiveness for reducing risky drinking (47). Despite lack of conclusive evidence about the effectiveness of SBIRT in various settings, in 2012, the Joint Commission put forward four optional performance measures related to tobacco and alcohol screening for hospitalized patients (48). The preponderance of research on SBIRT has been done in primary care settings, but Lauren Broyles, a nurse researcher and educator who has focused on nurse-delivered SBIRT in hospitalized patients, conducted a cross-sectional study of 370 patients hospitalized in medical and surgical units and found that patient acceptability of nurse-delivered SBIRT was high (49). The findings from this study are important in light of the recently approved measures for hospital accreditation (48).
To meet the need for nursing education to keep pace with this growth in knowledge related to alcohol use, the NIAAA is implementing an online curriculum for nurses with content on genetics, neurobiology, prevention, screening, risky use, withdrawal, treatment, health consequences, and legal/ ethical issues. Other examples of addiction training curricula are emerging to assist nurse educators to enhance their programs. Burns et al. (50) described an academic–community partnership developed to integrate SBIRT into the undergraduate curriculum of a university. The 11-module curriculum consisted of 8 hours of didactic education, 3 hours of skills practice in clinical sites, and 2 hours of simulation laboratory experience with case studies. The clinical experiences were completed in medical–surgical, psychiatric, obstetrics, geriatrics, and community health settings with clinical instructors trained especially for this evidence-based strategy. In addition to establishing an educational program for undergraduates, the university has made an online addiction module available for continuing education for nurses and other health care professionals. Similar initiatives are needed in the prelicensure curriculum if the RN workforce is to be adequately prepared to address the challenges of substance use and addictive disorders.
THE ADDICTION NURSE
While all RNs should have the requisite knowledge and skills outlined for the generalist, there is a need for addiction nurses, specialists with advanced knowledge and competencies related to substance use and addictive disorders. The Scope and Standards of Addictions Nursing Practice (2013) is currently being revised to reflect the continuum of substance use and substance use disorders emphasizing the need for prevention and treatment across all settings and specialties. The document, prepared under the auspices of the International Nurses Society on Addictions (IntNSA) and the American Nurses Association (ANA), sets forth the expectations of the professional role of nurses who specialize in addictions. According to the Scope and Standards, this “role commands knowledge of the fundamental biologic, behavioral, environmental, psychological, social, cultural, and spiritual aspects of human responses to the use of substances and engagement in behaviors that can lead to addictive disorders” (51). The Standards coincide with the usual steps of the nursing process and are intended to be applied to individuals, families, communities, and/or populations. The Standards of Practice include assessment, diagnosis, outcomes identification, planning, implementation (encompassing coordination of care, health teaching and health promotion, consultation, prescriptive authority, and treatment), and evaluation. Standards of Professional Performance relate to ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. Specific competencies for each standard are identified for the RN specializing in addictions and the advanced practice or graduate-level addiction nurse (51).
Through the Addictions Nursing Certification Board (ANCB), IntNSA has taken the lead in providing certification for the specialty. The highest standards of addiction practice are reflected by the Certified Addictions Registered Nurse (52) and the graduate-level certification (CARN-AP) (53). CARN eligibility requirements include current RN licensure with a minimum of 2,000 hours of nursing experience related to addictions as an RN within the last 3 years. CARN-AP requirements include a current RN license and a master's degree or higher in nursing. Applicants for the CARN-AP must have a minimum of 500 hours of supervised, direct client contact in advanced clinical practice working with individuals and families impacted by addictions and/or dual diagnoses; all 500 hours may be earned while in the master's program. The number of nurses holding the CARN was 700 in 2012. The CARN-AP was held by 50 nurses in 2012. The state of New York, through its Office of Alcoholism and Substance Abuse Services (OASAS), has endorsed the certification examinations by compensating nurses who work in inpatient facilities for the cost of the exam and sponsoring a certification preparation webinar (54).
ADDICTION NURSING WORKFORCE
The Addictions Nursing Certification Board (ANCB) of IntNSA recently published a Role Delineation Study of the Addictions Nurse (55). The study was designed specifically to describe the role and functions of nurses holding the CARN and CARN-AP and their demographics, including employment settings and educational background. A total of 1,027 invitations to participate in the study were sent with 924 responding, 221 who indicated that they were practicing in addiction nursing. Responses to the question about educational level indicated that 38.6% were BSNs, 32.9% were ADNs, and 7.6% had been prepared in a diploma or hospital-based program. At the graduate level, 13.9% held master's degrees, and 1.35% had doctoral degrees. The largest number of respondents (43%) indicated that they worked in hospitals, while 34.2% worked in treatment centers; 4.4% were engaged in private practice; 2.5% worked in schools; and 1.9% were in primary care. The majority of RN survey respondents (82%) worked full time, and 75% functioned exclusively as addiction nurses. RNs indicated that they spent the majority of their time providing patient care. APRN survey respondents also indicated that they spent most of their time providing direct patient care as clinical nurses, NPs, or consultants. Forty-nine percent of the APRNs reported that they had prescriptive authority. The final count of tasks [126] and knowledge statements (43) endorsed by the respondents was then used to compile content for the certification examinations. The results of this survey provide a glimpse of the addiction nursing workforce and suggest the complex nature of the practice by enumerating the tasks and requisite knowledge.
IntNSA is the specialty professional organization for nurses engaged in addiction nursing practice. IntNSA was founded in 1975 as a component of the National Council on Alcoholism. Mergers with the Drug and Alcohol Nurses Association and the Consolidated Association of Nurses in Substance Abuse, and the intent to become a global leader in the field, led to the organization's name change from the National Nurses Society on Addictions to IntNSA in 2000. The stated mission of the organization is “to advance excellence in nursing care for the prevention and treatment of addictions for diverse populations across all practice settings through advocacy, collaboration, education, research and policy development” (56). IntNSA has a membership of approximately 600 nurses. In addition to sponsoring the certification examinations, IntNSA holds an annual international education conference. The official journal of IntNSA is the Journal of Addictions Nursing, an international peer-reviewed quarterly publication. A feature of the journal includes interviews with addiction nurses who are engaged in innovative roles. The nurses describe their roles as addiction specialists and the paths they took to prepare for those roles. IntNSA also publishes the Core Curriculum of Addiction Nursing, a comprehensive overview of the specialty intended for clinicians, educators, and researchers, and in conjunction with ANA, the Scope and Standards of Addictions Nursing Practice.
Nursing roles in addressing at-risk substance use and the prevention and treatment of substance use disorders have expanded over the past two decades as more is known about the phenomenon of substance use. Standards of care and accrediting bodies have embraced the concept of universal screening for at-risk alcohol use by all health care providers (48). In addition, there is a better understanding of the impact substance use has on the burden of disease (34). The knowledge and competency needed by nurses at all levels of expertise (generalist and specialist) includes multiple components of care, screening, assessment, interventions, and referral for treatment. Current screening guidelines help nurses to identify those at risk for harm related to substance use as well as providing a process for providing interventions aimed at reduction of the harm associated with a patient's substance use. An area that is beginning to receive more attention is the incorporation of substance use into the nursing assessment of the relationship of current use to the health status of the patient. For example, assessment of the quantity, frequency, pattern, and duration of use provides important information related to possible drug interactions. The challenge is to keep pace with these changes through education to prepare all nurses to respond to the full spectrum of substance use, from prevention of at-risk use to treatment of substance use disorders, across the life span.
In conjunction with developing the knowledge and skills of all nurses across all health care settings and specialty areas is the need to build the nursing workforce in the specialty of addiction nursing. To meet the demands across the spectrum of care related to substance use, the need for nurses certified at the generalist or advanced practice level in addiction nursing is growing. For example, to meet the American College of Surgeons' and Joint Commission standards, hospitals need nurses with the specialty background to implement and evaluate these programs and provide the needed training. Nurses are acquiring a stronger voice in the field of addictions at the state and national level through the leadership of addiction nursing. To strengthen this voice, developing educational programs at the advanced practice level in schools of nursing should be a priority.
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