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An exploration of the role of substance misuse nurses in Scotland
Chapter 1: Introduction
Key points in this chapter With the increase of drug misuse over the past two decades, the role of the substance misuse nurse has increased dramatically. Previous research on the role of nurses working in drug problem/substance misuse services is minimal. Clinical responsibility resting with nurses may vary across services. Clinical responsibility between substance misuse nurses and doctors is not necessarily explicit in shared care models. Previous research on GPs in Grampian indicates nurses may be key gatekeepers to specialist services though little is known of the decision making process followed. Research is required to gain a better understanding of the role of the substance misuse nurse.
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Background to drug misuse service delivery in Scotland
The increase in drug use over the last two decades has led to more drug misusers presenting to primary care services and thus an increase in the number of health professionals involved in providing their care. Opiates such as heroin remain the predominant drugs of misuse in Scotland but polydrug misuse with alcohol and benzodiazepines is common. Psychostimulant misuse is comparatively low but there is evidence of this increasing (ISD, 2003). In Scotland drug services are focussed heavily on opiate treatment rather than stimulant treatment.
Drug services in the UK, and Scotland particularly, are largely community based. In the UK, for many drug-misusing patients seeking treatment to become opiate-free, their first point of contact with the health services is their General Practitioner (GP). In 1984 the Medical Working Group on Drug Dependence proposed a major role for GPs in the treatment of drug misusers (Gossop
et al., 1999). This was supported by the publication of treatment guidelines, which encouraged a greater number of GPs to treat this patient group (Department of Health (DoH), 1999).
The complex needs of drug misusers and a combination of different factors has lead to the development of effective collaboration between professional groups such as GPs, obstetricians, general psychiatrists, community pharmacists, prison medical officers, specialist drug treatment services, social services, voluntary sector and the criminal justice service (DoH, 1999). Some of these professionals have been widely researched (Matheson
et al. 1999; Matheson
et al., 2002; Sheridan
et al, 1996; Matheson
et al., 2003; Ralston and Kidd, 1996), whilst research in others such as the substance misuse nurse is scarce
1 (Rassool, 1996).
This multi-disciplinary approach (DoH, 1999) has been developed with the aim of:
improving service delivery
providing a balance in primary and secondary health care
providing treatment in a primary care setting
expanding the primary heath care team to include a wide range of specialist services
including patients in the treatment decision.
Shared care, a model of the multidisciplinary approach, is defined by the DoH as:
"The joint participation of specialists and GPs (and other agencies as appropriate) in the planned delivery of care for patients with a drug misuse problem, informed by an enhanced information exchange beyond routine discharge and referral letters. It may involve day-to-day management by the GP of the patient's medical needs in relation to those of her drug misuse. Such arrangements would make explicit which clinician was responsible for different aspects of the patient's treatment and care. These may include prescribing substitute drugs in appropriate circumstances." (DoH, 1999).
The exact role of the substance misuse nurse within such shared care arrangements remains to be explored.
Over the two years it has taken to conduct this research there have been further developments, multi-disciplinary working has moved from shared care to the Joint Future Agenda and the concept of Integrated Care for Drug Users (EIU, 2002). Understanding the role of substance misuse nurses and how they relate to and communicate with other health and social professionals will help the planning and operation of integrated drug services.
Role of the substance misuse nurse in Scotland
In line with the general increased demand for services for drug misusers, the role of the substance misuse nurse has increased dramatically in recent years. Substance misuse nurses work in many different settings with drug misusers, and have different approaches to care. Their skills include assessing drug misusers' needs, selecting treatment options, counselling, and carrying out other treatment procedures such as urine testing. Some GP surgeries have designated nurses who are assigned to the care and management of their drug-misusing patients. In other cases nurses employed by specialist service largely work in a general practice setting. Some evidence suggests that the role of the substance misuse nurse can be particularly demanding and stressful. This is mainly due to the increasing need for specialised skills in areas such as assessment, communication, counselling, encouraging patient involvement in decision making, organisational factors such as changes in services, loss of funding and in particular the lack of training and support for staff (Happell and Taylor, 1999; Farmer
et al., 1999, McMillan, 1997).
It is likely that there are variations in the role and expectations of drug specialist nurses across Scotland, depending on location and setting. For example health board areas may have different policies in place; different teams in general practice settings may also vary in the level of decision making delegated to the substance misuse nurse, with respect to treatment and prescribing. Yet there is a 'grey area' surrounding prescribing of substitute drugs since nurses cannot currently sign prescriptions and the signatory under current legislation, has clinical responsibility (Misuse of Drugs Act, 1971).
The Association for Nurses in Substance Abuse in Scotland (ANSA) was formed in 2000 as an interest group. This organisation has published a series of guidance documents for nurses working in the field of drugs and alcohol. This organisation is still relatively new and under development. ANSA is funded by members subscription and does not receive any central funding or support.
Previous research and gaps in knowledge
Previous research on substance misuse nurses specifically is very limited. What has been done is either on a small scale or is out of date relevant to recent changes in service provision. Some research assessing the attitudes of different groups of nurses to drug misusers (including substance misuse nurses) has been conducted (Carroll, 1993; Carroll, 1996). One further study has looked at prison nurses' attitudes (Carroll, 1995
a) and another at midwives' views of perinatal drug use (Selleck and Redding, 1998). Other studies have started to look at nurses' role in more depth but only on a limited scale (Happell and Taylor, 1999) and not in the UK. There are numerous studies published which address other health professionals' attitudes towards drug misusers (George and Martin, 1992; Carroll 1993, 1995
a 1995
b and 1996; McGillion
et al., 2000; Howard
et al., 2000; McKeown
et al., 2001; Matheson
et al., 2003). However, there has been limited research conducted into the attitudes of drug misuse nurses.
As it is not known what views nurses hold towards their client group or the effectiveness of particular treatment approaches, it is not known what impact their views may have on service delivery. Nurses' delivery of services may have an impact on treatment retention and outcomes. Alternatively, some evidence does exist which suggests that the substance misuse nurse has a more positive attitude and greater knowledge of the issues surrounding drug use than nurses working with drug misusers in other areas such as Accident and Emergency, general practice and the penal system (Carroll, 1995
a).
From previous research with GPs in Grampian (Rae
et al., 2001), only 8% of GP respondents indicated their Substance Misuse Service (SMS) nurse had 'no' influence on which treatment to offer in opiate dependency, whereas 20% said the SMS nurse had 'total' influence and 72% had 'quite a lot' of influence. Thus nurses were key gatekeepers to the range of services (methadone maintenance, inpatient or community detoxification etc.) available to drug misusers. This raises questions about how nurses undertake decision making: do they have a rigid approach, following guidelines such as the Drug Misuse and Dependence: Guidelines on Clinical Practice (Department of Health, 1999) or local protocols; how influential are patients, GPs, and the consultant in the decision-making process; how much judgement is involved?
This brief overview of the literature has identified substantial gaps regarding the role of the substance misuse nurse compared with other professionals working in the field of drug misuse. Little is known about their demography, current practice, experiences, attitudes or overall role in the treatment of drug misusers. This study was designed to fill these gaps in knowledge of the structure and delivery of services which can provide baseline data for future drug policy making,service development and workforce planning
This two year research project was funded by the Effective Interventions Unit (EIU) through an open research competition conducted in 2001 under the Scottish Executive's Drug Misuse Research Programme.
Study Aim
The aim of the study was to describe and analyse the role of substance misuse nurses in the provision of drug misuse services in Scotland.
Specific Objectives
1. To identify the population of specialist nurses working directly in the management of illicit drug users in Scotland.
2. To gain baseline data from the above population on their demography, caseload, services provided, level of interaction with other health professionals.
3. To compare their attitudes to drug misusers with other health professionals.
4. To explore their beliefs about the effectiveness of different treatment options.
5. To compare certain aspects of practice to general practitioners.
6. To examine their role in the initial client assessment.
7. To examine their role in decision making about a client's management.
8. To describe their decision making process.
9. To explore their relationship with other professionals.
In addition to these nine objectives two further issues were highlighted early in the research following the survey questionnaire and piloting of interview schedule. A decision was taken to explore these issues further in interviews. Therefore two further objectives have been added:
10. To explore the issues of stress at work.
11. To examine nurses' views of safety procedures at work.
Structure of this report
Chapter 2 describes the methods used. The study findings are presented in
chapters 3-8 by integrating the findings from different data collection methods. Findings are presented around the main study objectives but also structured to reflect the structure and process of care thus some objectives are combined in some chapters. In
chapter 9 findings are discussed and interpreted in the wider context of other practice, policy and research developments and recommendations for these areas made. A comprehensive report with more detailed results and methods is available from the research team.
1 It is acknowledged that nurses working in this field may be referred to using a number of titles e.g. substance misuse nurse, drug specialist nurse. In the interest of continuity, the term 'substance misuse nurse' will be used throughout this document.
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