The Scottish Government

« Previous | Contents | Next »

Listen

An exploration of the role of substance misuse nurses in Scotland

Chapter 6: Making treatment decisions

Key points in this chapter Clients were actively encouraged to participate in treatment decisions. Although 84% of nurses reported they were expected to follow a treatment protocol only 44% said they always did follow a treatment protocol (for any treatment). Eighty-six percent (86%) of nurses had seen the National Clinical Guidelines (DoH, 1999), and those who were interviewed felt that these provided a good framework for treatment, although they were perhaps lacking in detail. Nurses reported that they often consulted widely with other health professionals but, most frequently, with the client, before making a treatment decision. A third of nurses reported that they sometimes wrote prescriptions for a doctor to sign (which is possible if the doctor has a handwriting exemption certificate). Seventy percent (70%) of respondents felt nurses should be able write prescriptions but only if this practice was restricted to experienced nurses with appropriate training. Comparing nurses and GPs beliefs: When making treatment decisions nurses were less influenced by the attitude and behaviour of drug misusers than GPs. When making treatment decisions nurses were more influenced by societal factors than GPs. Nurses were less likely to favour detoxification than GPs as a treatment approach although 83% of nurses agreed that a community based detoxification programme was an effective tool. GPs were less confident than nurses in successfully managing poly drug users. Both GPs and nurses were divided about their beliefs about the effectiveness of dihydrocodeine.

Nurse-patient interaction during decision making

During the observations of consultations nurses demonstrated a partnership with their clients, encouraging them to be actively involved in the development and advancement of their treatment. Clients' points of view were actively sought and they appeared comfortable to freely express themselves, speak openly and ask questions. For example, field notes for one first assessment read "Nurse very relaxed and does not use leading questions". During this stage of the consultation nurses frequently used open questioning when exploring the above issues and continuously emphasised the importance of clients' subjective experiences. Nurses went on to discuss the benefits and risks of various treatment interventions and procedures to inform clients, which would enable them to be actively involved in a shared treatment decision. During this point clients appeared to adopt a passive recipient role absorbing the information, which was being presented to them.

For clients who were already engaged in treatment, nurses would explore their satisfaction with treatment and actively encourage clients to express any worries or concerns. This was done by using verbal and non-verbal prompts, for example asking direct open question, using hand gestures, facial expressions, nodding head in agreement and leaning forward towards the client if they were upset or discussing a sensitive issue. Generally most clients spoke clearly and fluently, and most actively engaged in the consultation.

Clients who had experienced some sort of difficulty since their last consultation would be asked to identify triggers or stressors, which they thought might have influenced their behaviour in either a positive or negative manner. In most cases clients appeared open and honest. Nurses then went on to introduce strategies, which may be developed and adopted by clients to help them avoid similar situations in the future.

The relative importance of factors influencing treatment

In the questionnaire nurses were asked to indicate how certain factors might influence their treatment of a drug misuser. As this exercise had been previously conducted with GPs it was possible to compare results ( see Table 7). Generally, nurses were more strongly influenced than GPs by societal factors than patient factors. The factor that had the least influence for nurses and GPs was gender whilst the factor with the most influence on treatment decision for GPs and nurses was pregnancy. The most noticeable differences between GPs and nurses was that GPs reported that they were more strongly influenced by patients' attitude and behaviour. GPs were less influenced by societal factors than nurses.

Use of guidelines

The majority of nurses had guidelines they were expected to follow when carrying out their work. In 1999 the Scottish Office Department of Health produced Guidelines on Clinical Management of Drug Misuse and Dependence (the Orange Guide, DoH, 1999). A copy had been seen by 86% (n=161) and of these 87% believed it had influenced their practice. In other cases locally drawn up protocols were used. In interviews nurses referred to both. Nurses working with clients requiring substitute prescriptions and those working in detoxification emphasised the value of the Orange Guide in ensuring safety and in assuring GPs of appropriate prescribing. One nurse said:

"It does have quite a good framework and I think in terms of for us working with GPs it gives them the reassurance. As long as you are working within the guidelines then you have a relative degree of safety". Nurse 23, G Grade

However, the Orange Guide was also seen to have limitations:

"It doesn't go into huge amounts of detail. It kind of skims the surface but as far as ground rules go it's quite helpful, certainly when you first come into the job". Nurse 5, B Grade

Nurses also referred to specific protocols geared to particular services:

"Needle exchange is very tightly monitored. We have very tight levels that we have to work within. Its got to be first level, registered nurses, you can only give out a certain amount, you've got to do certain things which is checking sites etc so our protocols are very tight to deal with actual mechanics". Nurse 7, H Grade

One nurse mentioned the Coordinated Addictions Network as providing a standardised approach to assessment which amounted to following a set of investigations based on good clinical practice.

Table 7 Factors influencing treatment of drug dependency (GPs, n = 583, nurses minimum n=168)

	Strongly Influence		Partly Influence		No Influence		Not Sure
Patient Factors	Nurse%	GP%	Nurse%	GP%	Nurse%	GP%	Nurse%	GP%
Age	17.8	4.2	48.6	26.7	31.4	66.0	2.2	3.1
Gender	6.6	0.5	26.5	8.7	66.3	88.9	0.6	1.9
Carrying an infectious disease 1	23.2	14.4	43.8	31.5	31.4	51.8	1.6	2.3
General health	28.6	10.3	48.6	39.8	21.6	47.5	1.1	2.4
Length of drug use	18.3	10.8	54.3	45.5	27.4	41.1	0	2.6
Improved standard of living	29.5	21.0	35.0	47.3	23.5	27.0	12.0	4.6
Nature of drug use	31.7	17.1	45.7	44.1	22.6	35.7	0	3.1
Poly-drug use	26.9	21.1	49.5	48.4	23.7	27.2	0	3.3
Main drug of use	29.3	19.9	43.5	45.6	25.5	31.4	1.6	3.1
Attitude of patient	34.6	65.1	44.3	26.7	20.0	7.1	1.1	1.0
Behaviour of patient	30.6	62.7	52.7	29.8	15.1	6.6	1.6	0.9
Being pregnant	81.0	52.5	14.3	29.8	4.8	15.3	0	2.4
Societal Factors
Reduced transmission of infectious diseases	55.1	35.5	31.9	47.7	11.9	12.7	1.1	4.0
Reduced rate of problem drug use 2	49.2	29.7	39.3	49.0	10.4	16.7	1.1	4.7
Improved mortality rates	50.3	32.5	35.0	47.2	12.0	15.3	2.7	5.0
Improved morbidity rates	47.0	33.3	38.4	48.6	11.4	13.5	3.2	4.5
Reduced crime rate	31.4	28.7	48.6	46.4	17.8	20.0	2.2	4.9
Effect of family and friends	33.9	36.6	49.2	47.0	14.2	12.5	2.7	3.9

GPs question worded slightly differently: ¹HIV/ Hep B,C; ²Reduced use of illicit drugs

Other sources consulted to make decisions

In the questionnaire 84% of nurses reported that they were expected to follow a treatment protocol when considering a patient's/client's management; this was not influenced by Grade. However, when asked how they decided on a treatment plan only 44% said they followed a protocol. As shown in Table 8, nurses reported consulting a range of individuals when deciding on a treatment plan. The patient was the most frequently consulted individual.

Table 8: Information sources consulted in forming a treatment plan

Treatment plan1	N=192	%
Decide in consultation with the patient/client	164	85.4
Decide in consultation with a consultant	111	57.2
Decide in consultation with GP	103	53.1
Decide in consultation with other health/social care professionals	83	42.8
Decide in consultation with other Substance misuse nurses	97	50.5
Decide by self	40	20.8
Follow a protocol	85	44.3

¹

Participants selected all that applied

Nursing grade and age of nurse did not influence what resources were consulted in forming a treatment plan. However, more rural-based nurses than urban/city centre indicated they would follow a treatment protocol.

Prescribing medication

Nurses were asked in the questionnaire whether nurses should write prescriptions for medication and if so what level of nurse should undertake this: 70% of nurses felt that only specifically trained experienced nurses should sign prescriptions ( see Table A4, Appendix 4).

In practice 29% (55/189) of nurses wrote prescriptions, for doctors to sign, for substitute drugs: of those 55, 28 did so 'sometimes' and 27 'always'. ^** The most commonly prescribed drugs were methadone, diazepam and lofexidine ( Table A5 Appendix 4).

In interviews nurses were asked how they decided on a commencement dose for clients who were starting a methadone programme. Reported commencement doses of methadone ranged from 10 to 40mg, titrating upwards to a dose, over a number of hours or days, until the client felt comfortable and was experiencing little or no withdrawal symptoms. Nurses indicated that the starting dose depended entirely on the assessment of a client's individual needs:

"The nurses don't decide on that at all. We would discuss that with the medical staff and the consultant. The upper starting dose here as a policy is 40mls of methadone which would be the first daily dose, it would never be more than that." Nurse 2, G Grade

A nurse in another area suggest a lower starting limit:

"We really don't commence anything above 25 mls. Occasionally I have commenced someone on 30 mls but that is rare." Nurse 23, G Grade

However, many indicated that they did have some input into the starting dose:

"It's very much a medical decision. We have input into that, we're allowed to voice an opinion but the decision will be made by the medical staff." Nurse 2, G Grade

However from questionnaire findings only 30% of nurses believed prescribing should only be a medical decision, not a nursing responsibility ( see table A4, Appendix 4). Indeed in interviews some nurses reported that they would often suggested a commencement dose to the GP, who would often then sign a prescription issuing that amount.

Treatment options and decision-making

In interviews nurses were asked to give more detail about how treatment decisions were made. In particular nurses were asked if clients approached them with particular treatment requests. One nurse indicated that the world-wide web was a major source of information for clients:

"Some people come with more knowledge than others because they have got computers and are extremely smart. They get on the internet and read up all about it so they have got a very clear idea of what they want…I would say most clients have a pretty clear idea what they want from the service before they come through the door. They often have no idea what our service can offer, but they know what they want from us." Nurse 13, G Grade

Another indicated that clients did not necessarily know what was good for them:

"I mean obviously if somebody comes to me with a particular treatment in mind then we need to look at that and sometimes you have to advise them that their ideas about what might work for them are maybe not appropriate at this stage. That's maybe somebody who's coming that's been injecting ten bags of heroin a day for the past couple of years and wants to detox in a week. Research will tell you that that's inappropriate it's doomed to failure and whatever else." Nurse 18, H Grade

From interview data it appears that clients are encouraged to actively participate in the decision-making process and to express their expectations of treatment, care and support. One nurse explained:

"I think most of them [the clients] have an idea that [our service] does prescribe methadone. The format that I take is that I ask them their view and what they think that [our service] can provide for them and that usually starts a discussion about the expectations and what we can actually offer them and it gives me an idea of what their perception is and what they are hoping to achieve and whether it is a prescription and then I would ask them what they hope to gain by their prescription and usually starts off the discussion. Most folk have the idea that [our service] prescribe but some also have the perception that we prescribe very quickly and they expect a prescription first day. That is slowly changing there are fewer people asking for a script straight away." Nurse 11, G Grade

Starting and ongoing treatment

In interviews the issue of starting a prescription was often mentioned and the subsequent need to arrange a pharmacy placement. Whilst some nurses contacted the pharmacist others left it to the patient. The latter method was seen as a demonstration of a patient's commitment to treatment:

"I will say "You know, if you are going on methadone it is going to be daily supervised in the chemist, and it is up to you to find a chemist that will take you on" and that gives them the opportunity to go round and find one…It is giving them motivation to do it and they are quite capable to go round a chemist and just say that they want to start this and have you got a space for me and again we have not had any problems with that". Nurse 20, G Grade

Routine weekly assessments were arranged for clients who were already participating in treatment but were still perceived by their nurses as 'chaotic'. Generally clients considered stabilised were seen on a fortnightly or monthly basis. Discussion during these consultations focused on clients' general health, experiences since last meeting, concerns, achievements, goal setting, clients' reflection, and summarising of consultation. Urine samples were sometimes requested.

Comparing treatment beliefs to general practitioners

For some questionnaire data it was possible to compare with data from previous work conducted by the University of Aberdeen with GPs (Matheson et al., 2003). This allowed a comparison to be made between nurses and general practitioners on approach to treatment and beliefs regarding the organisation of services. Table 9 compares nurses' beliefs with GPs' beliefs about the effectiveness of treatment.

There were some notable differences in beliefs about treatment:

1. Nurses generally did not favour detoxification whilst many GPs still consider this preferable. However although nurses did not consider this to be preferable 83% agreed that a community based detoxification programme was an effective tool.

2. Nurses were more confident than GPs in successfully managing poly drug users.

3. Both GPs and nurses were divided in their beliefs about the effectiveness of dihydrocodeine.

However, there was broad agreement that a holistic approach to treatment was necessary.

Table 9 Nurses'and GPs' beliefs about the effectiveness of treatment and organisation of services(min n=187 for nurses and n= 583 for GPs)

Comparative attitude Statements	Respondent	Strongly agree %	Agree %	Disagree %	Strongly disagree %	Uncertain %	Missing value %
A detoxification programme is always preferable to a maintenance programme.	Nurse	0.5	5.8	50.5	38.9	4.1	1.0
	GP	14.8	28.1	25.2	3.5	28.1	0.2
A holistic approach toward the problems associated with drug dependency is necessary in order for any care plan to be successful. (e.g. combined medical and social care).	Nurse	52.6	43.7	2.6	1.1	0	1.0
	GP	17.5	63.5	2.9	0.5	14.9	0.7
Prescribing dihydrocodeine instead of methadone for maintenance has advantages for some clients.	Nurse	5.3	35.1	29.3	10.6	19.7	2.1
	GP	1.2	23.5	21.6	12.0	41.5	0.2
Drug misusers should only be seen centrally by specialist services, rather than by GPs.	Nurse	4.2	12.1	41.6	36.8	5.3	1.0
	GP	30.4	35.7	15.8	4.3	12.7	1.2
If a client is a poly drug user it is unlikely that any treatment will be successful. 1	Nurse	1.1	3.6	62.6	29.4	3.2	2.6
	GP	31.6	54.4	5.0	0.5	8.2	0.3
Having a drug dependency problem should in no way affect a client's access to health care services of any kind.	Nurse	72.1	25.3	1.6	0	1.1	1.0
	GP	29.2	59.7	4.5	0.7	5.8	0.2
I have no sympathy at all for drug misusers	Nurse	0.5	1.6	26.8	71.1	0	1.0
	GP	2.6	6.5	57.3	19.6	13.4	0.7

¹

This question was worded slightly differently for GP: " I am less confident in the success of any treatment if the patient is a poly drug user" (Matheson et al., 2003).

*^* Note: nurse can write prescriptions for controlled drugs for medical practitioners to sign only if the medical practitioner has an exemption certificate.

« Previous | Contents | Next »