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An exploration of the role of substance misuse nurses in Scotland

Chapter 5: The initial assessment of clients

Referrals for assessment

During interviews nurses said that they conduct initial assessments for clients referred to their service from GPs, maternity services, criminal justice, or voluntary services. Few nurses reported that their services had a self-referral scheme. Nurses explained that the depth of information provided in referrals about a client's drug misusing history or behaviours differed considerably.

Another issue was that the waiting time between referral and assessment could be a few days or a few months. The following is a typical example:

"..because of the volume of work that comes in there is usually a two to three week waiting time from referral entry, two week to be seen for the initial assessment, so if you added that on to it as well, you would be looking at possibly nine weeks from the point of referral to the point of a prescription." Nurse 14, Grade G

Although, there was general acceptance that some waiting period was almost always unavoidable, all were aware there were potential consequences, especially for chaotic users. One nurse stated:

"Because we had a waiting list things could change quite dramatically in the three or four months...a long time in the life of a drug addict". Nurse 13, Grade G

Indeed when asked specifically about waiting times in the questionnaire 60% agreed there was a long wait between GP referral and appointment.

As a result of the inconsistent level of information provided and the changes that could have taken place since referral, all nurses interviewed indicated that it is part of the treatment process to conduct their own assessment of new clients. This is always done during the first consultation between the nurse and the client.

The assessment

Purpose

From interviews and observation the purpose of an assessment was to identify the needs and expectations of the drug-misusing client and make decisions about their treatment, care and support.

Areas explored

The aims of the first assessment, as described by nurses were to: determine type of drugs used, drug-misusing history; assess problems associated with drug misuse; assess risk; identify medical, mental, social and environmental needs; determine client's motivation; explore client's treatment requests and expectations; inform and explain the treatment options available to clients; and determine those most suited to their needs. These assessments took the form of direct discussions between the substance misuse nurse and the client. Local protocols were generally followed. These might be based on national guidelines as some nurses indicated that they followed the guidelines in the Drug Misuse and Dependence - Guidelines on Clinical Management. Others indicated that they always used a Substance Misuse Register 24 (SMR 24) which is not an assessment tool but a monitoring form, and was devised to record systematic information on the characteristics of drug misusers. One nurse explained:

"We have quite a standard format. What we do is an initial assessment and during that time which is about a half hour appointment we would go through the standard form and we would use that as the basic assessment. So we are looking at: Where do you live? Who their GP is, who referred them, I would need to know if they receive anything on prescription for their drug use, what their illicit drug use is. If they are using any drug on top of their script." Nurse 10, H Grade

Another nurse, who works with young people, said:

"We're sort of looking at general information, physical and health, school, education, social and social support from the family as well." Nurse 12, G Grade

From observation and interviews it was evident that assessments explored similar content and took similar format regardless of the NHS area. These assessments explored the reasons for presenting for help with drug misuse: the age when starting drug use; types of drugs used; routes of administration; amount and cost of drugs used. Initially nurses would attempt to investigate clients' medical history and general health requirements. This was usually done by a physical examination, to assess complications of drug misuse for example abscesses, needle track marks, poor nutrition, deep vein thrombosis, pneumonia and dental disease. Other complications included anxiety, irritability, and blood-borne diseases such as HIV, Hepatitis B and C. Most of the nurses, especially those who worked alongside needle exchange and harm reduction clinics, also explored the need for new syringes and needles, injecting practices, making sure that clients were aware of how to inject properly with minimal risk, sexual health such as use of condoms, knowledge of HIV, Hepatitis B and C transmission. CPNs indicated that they would also explore the client's mental health history such as previous episodes of accidental or intentional overdose, periods of depression, suicide or self-harm. Additionally, clients' general behaviour was investigated to identify factors such as irritability, anxiety, and restlessness as these may be associated with intoxication or withdrawal.

"I would be focusing on the physical elements of their addiction and what their experience of withdrawal had been like in the past and their anxiety around any withdrawals that they might experience." Nurse 8, G Grade

However, many nurses tended to extend assessments to incorporate a more psychosocial model of investigation. All expressed the need to explore their client's circumstances on a wider scale and this meant exploring and treating more than the client's physical needs. Therefore, social, economic and family situations, housing status and general welfare of clients were also explored. This included an overall investigation of the client's history of involvement in the criminal justice system. One nurse explained:

"We'd look at their accommodation, who they live with and if they are drug users. If they have been in prison, have outstanding charges or pending court cases. As a background as well you might ask people when they first started using drugs, why they felt they started using, when they first felt that their using became a problem and that's usually enough to be going on with." Nurse 10, H Grade

This in-depth exploration of the client's background and current situation is conducted to establish immediate medical needs and to highlight any additional factors which might warrant further referral to appropriate services, such as social work, dentists or housing. Factors which determined such referral included having no fixed abode, living with other drug users, living with children considered to be at risk, or suffering from acute dental problems. In addition employment and financial status were explored to establish how the clients were spending their time and funding their drug use.

Nurses indicated that it was also important to know if clients had previously attempted to reduce or stop their drug taking. If this was the case they explored whether or not they had attempted this on their own or if they had been in touch with treatment services before, and if so which treatments had they previously attempted.

This holistic approach to assessment was viewed by nurses to be crucial to ensure that clients were given the most appropriate treatment, thus giving them the best chance to gain control of their lives. From observation, nurses used simple open questions which enabled exploration of issues.

In addition, during observed consultations nurses always requested a urine sample on their first assessment to confirm the types of drugs being used such as amphetamines, benzodiazepines and heroin. This was routinely done at the end of the first assessment and, as noted in interviews, randomly throughout treatment. All nurses indicated that clients would not receive prescriptions for substitute drugs until they had received the results of the first urine sample. This usually took seven days and if the results were positive (as would be expected in those seeking treatment for a drug problem) they would then conduct one or more consultations with clients to discuss treatment options before deciding with the client the type of treatment and dose most suitable to the client's needs.

From observation, clients involved in first assessments were asked about their plans for the future. Most clients aimed for short-term goals, such as putting on weight or developing a regular sleep pattern. Other clients, observed during routine assessments were more likely to explore longer-term goals such as gaining employment or participating in further education. For the majority the main goals appeared to be to: develop a better relationship with their families and to develop and implement strategies for resisting drug use.

Closure

Nearing the end of the scheduled time nurses were observed to adopted a reflective role to ensure that they understood what clients had told them. They summarised issues and information and checked that clients understood what had been discussed during the consultation. Questions tended to more closed and the conversation ended with an agreed date for the next consultation.

"Towards the end of the assessment we would be trying to establish what the patient might be looking for you know from the service, what they think might be helpful in terms of follow-up, you know, what they think their immediate needs are and trying to draw up some kind of action plan or care plan." Nurse 15, G Grade

What happened next?

Nurses were asked in interviews how many times they would consult with their clients before deciding on their treatment plan. The number of consultations to complete an assessment and develop a treatment plan varied according to clients' needs and treatment requests. Before deciding on a treatment plan most nurses would expect to consult with their clients on at least two or more occasions. Even then, a prescription would not be given until toxicology results from a urine test confirmed positive drug use. One nurse explained this in more detail:

"It is likely that the process would be two initial assessments and a urine sample which could take a week to ten days to come back. Then a further assessment would have to take place which is slightly longer than the initial assessment, then there is a management discussion with the consultants and at that point it would determine if they need a substitute prescription based on the assessment information and the discussion with the consultants. If they were thought suitable for a methadone programme then it would be the next available space." Nurse 5, B Grade

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