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An exploration of the role of substance misuse nurses in Scotland

Chapter 7: Multidisciplinary working

Relationships with other professionals in the field

In the questionnaire the proportion of nurses who rated their relationship with other professionals as good/very good were as follows:

• Community Pharmacists, 83%

• GPs, 77%

• Health Visitors/Community nurses, 69%

• Hospital Doctors/Consultants, 58%

• Social Workers, 57%

• General Midwives, 49%

• Policy Makers, 26%

Nurses felt it was important to be able to discuss issues with all of the above professionals. Over three-quarters of nurses felt they had the opportunity to discuss services for drug misusers with other substance misuse nurses, social workers, GPs and pharmacists. Table 10 indicates that fewer nurses felt such an opportunity existed with policy makers. Over 90% of nurses felt that it was important to discuss issues with each of the professional groups listed, and over 50% of nurses felt that the level of communication was sufficient with other substance misuse nurses, pharmacists, social workers and GPs and not sufficient with policy makers. Nurses working with drug misusers for more than eight years were more likely to have the opportunity to discuss services for drug misusers with policy makers (p<0.01).

General Practitioners (GPs)

In the questionnaire most nurses reported working regularly with GPs; and 78% believed that GPs/doctors 'highly' or 'reasonably' valued substance misuse nurses.

In interviews nurses generally described positive relationships with GPs. What made relationships work well seemed to be associated with GPs valuing the nurses' skills and knowledge. However this seemed to be dependent on the individual GP.

"It's usually individual GPs, you know, it's just when you're sort of working with them its good. I find that they are willing to listen to you". Nurse 14, G Grade

Others reported a very good working relationship:

"We have actually got quite a healthy relationship with the GPs. We don't seem to have any problems on what we recommend what the patients should be starting on. The GPs usually follow that on, take our advice". Nurse 20, G Grade

These quotes also demonstrate that it can be the nurse taking the lead in recommending treatment and doses of medication. However the division of labour between nurses and GPs was not clear or consistent.

Pharmacists

Nurses described having good relationships and frequent contact with pharmacists. Although some contact occurred for purposes of arranging pharmacy placements for clients the relationship had a broader role. There was evidence of nurses and pharmacists working together for the well-being of the client:

"I am in and out of the chemist all the time so we have got a really good relationship with them and they will phone us if people are missing or if they have any concerns. Even if they have someone on a monthly prescription they can phone and say "so and so doesn't look so well" and I can say "Okay, I will leave them a wee note, telling them to come to the clinic, stop their prescription, give it up until that day and that is your appointment" and I'll get them to come in". Nurse 23, G Grade

It was acknowledged that pharmacists sometimes had a difficult role to play and there was evidence of respect for that:

"The community pharmacists are really good, really good. Most of them, I think nearly all of them, are on board and it's a job I wouldn't envy. …. if we send a prescription that is reducing, they're the first kind of point of contact that the person's frustration hits so the pharmacists do put up with a lot so our relationship with them is good because it has to be good". Nurse 5, B Grade

Where nurses worked with clients requiring substitute prescriptions, their involvement in assisting clients in finding a pharmacist varied among services. In many cases, the nurse or another service representative would make first contact with the pharmacy. In some settings this was because that was how pharmacists liked it to be or because it was part of a local treatment protocol. Nurses also arranged pharmacy placements for clients because it provided some certainty that the prescription would be dispensed. One nurse stressed the importance of keeping pharmacists well informed:

"I like to do that so they know the patient is the genuine article". Nurse 19, G Grade

Other health professionals

Nurses mentioned having good relationships with midwives and health visitors. Contact was not made routinely but, when required, was found to be valuable. Joint working between substance misuse midwives and health visitors seemed to have been facilitated where relationships were well established:

"I have been with the same surgery for so long it is the same health visitor, so the health visitor and I have a great relationship, so all the mums who have kids we are all working together, so they are getting a really good service". Nurse 19, G Grade

Social Services

Relationships with social care professionals were less consistently reported as favourable when compared with those they had with other health professionals though there was some evidence of effective joint working. One nurse described the following relationship:

"I'm thinking of one client in particular, the health visitor, the social worker and myself, or one of us, tries to see this person every week and we're on the phone to each other every week saying "Have you seen her?" …. she's so elusive and so somebody knows that somebody is seeing and monitoring this girl and come the case conference we will all be able to put in our thoughts and findings". Nurse 10, H Grade

Another nurse described a set up where the health and social care services kept one another informed on a monthly basis. Some nurses described difficulties in working effectively with social care professionals. This was sometimes due to a lack of shared planning:

"We do try our best to have the closest links as possible but some of them tend to work quite isolated within the social work departments and some of them have got drugs workers themselves a lot of the time, I think it is what is called treatment developments, they seem to have developed or set up these services without really the consultation of the whole, the other people who are already doing the job…sometimes you feel that there could be better co-ordination with that". Nurse 3, G Grade

Another nurse described feeling undervalued:

"I think that social workers do not see us as equal professionals. They don't even know who you are. They don't really take an interest. You are just someone who is expected to do a wee job "Take a urine sample for me please" ". Nurse 22, G Grade

Confidentiality across services

Maintaining client confidentiality and knowing when to seek the support of other professionals may pose difficult dilemmas for substance misuse nurses requiring them to weigh up issues of safety and trust. Nurses were asked how they handled such situations. When the safety of the client or other individuals were under threat, nurses were clear about informing other services and they would be open about this to their clients:

"I will ask them permission however if I felt somebody else was in danger or they were in danger then I would take it upon myself and I would inform them that I was contacting them [social services] and I would go ahead and do that" Nurse 1, G Grade

Although clear about when to inform other services, doing so could be distressing as this nurse noted after witnessing a child play acting part of an injecting ritual:

"This child was obviously seeing something and I was going to have to do something. She wasn't particularly happy [the mother]…if you see something like that you have to tell the authorities because it's not fair. But that's quite rare because most female drug users I think are actually quite good with their children but this case was quite upsetting, then I did beat myself up about that". Nurse 7, H Grade

Nurses reported that clients with children often had fears that their substance misuse problem might threaten their custodial rights, although this rarely occurred:

"Some patients are quite concerned that information that they're drug users or in drug treatment goes to social work department will be, they'll have their children taken off them. Saying that, it's not common. It's not something we hear very often. Most people by the time we see them they seem to already have social workers allocated to the families. There's already been problems picked up earlier". Nurse 6, G Grade

Having clear guidelines about how to deal with issues that require breaking confidentiality was viewed as helpful to nurses.

Integrated Drug Services and the Joint Future Agenda

Nurses were asked if they were aware of the Scottish Executive's Joint Future Agenda and if so whether they thought it would be useful to them when treating their drug-misusing clients. The Joint Future Agenda is The Scottish Executive Strategy to promote working between local authorities, NHSScotland and other relevant organisations to improve community care (Scottish Executive, 2000). This spans all groups in the community but has been applied in the drugs field through the development of Integrated Drugs Services. All nurses had heard about Joint Future but few were aware of its key elements. One nurse admitted:

"…Joint Future. Is that regarding similar kinds of shared care?" Nurse 5, B Grade

Most nurses showed some awareness of what the aims of the Joint Future Agenda and agreed that there was scope for such strategies to be adopted across the services. One nurse said:

"I know we've got to work increasingly closer with our Social Work colleagues and Community Drugs Teams. We've had meetings about the joint assessment tools and I think it could be a good thing." Nurse 2, G Grade

In some areas services were already working in collaboration with others and did not feel that they required the changes suggested in the Joint Future plan:

"We do a lot of joint working though we don't sit in the same room together. Community Addiction Teams consist of Social Work and health worker working together which sounds great, but put a substance misuse nurse in there just to get a shared care element, its daft. "We work close enough from a distance." Nurse 20, G Grade

Another expressed concern regarding their service's identity and relative importance within an integrated care plan:

"I think there is a lot going on for our team at the moment with the Joint Futures which is more or less wiping out our drug service and I think it is really important that we consider keeping shared care, not in a diluted form but as a strength, as a strong body because it works well for a lot of people" Nurse 22, G Grade

Joint assessments were not considered appropriate for some clients. Clients approaching a service such as social work might not be ready to admit their drug use or approach drug misuse services. One nurse, working in a community detoxification service stated:

"We as a service have made a decision not to accept social work referral. The reason for this is that if people have got a heavy amount of social work input then we have to question whether they are ready to be doing a detox for example, because we feel if there is a lot of social work input then it suggests social chaos which is not in keeping with being able to support a detox programme. So you see there are some problems which could arise if we are using the same assessment tool and also because we would be inundated with inappropriate referrals from social work and some homelessness units." Nurse 8, G Grade

This quote also indicates this nurse's service is currently working against the basic principles of the Joint Future Agenda. In cases like this there may be more barriers to overcome in implementing Integrated Drug Services. Others were found to be working towards a joint assessment procedure as suggested in the Joint Future plan. In contrast, one nurse expressed strong opinions about what the joint assessment might mean for himself and his colleagues:

"… I think it's just going to be more paperwork for everybody because you're going to have the common assessment for joint future your own assessment and you're going to have all your own databases and things to fill in…." Nurse 10, Grade H

However, the majority of nurses were of the opinion that the Joint Future Agenda could be beneficial for both themselves and their clients as they felt that the sharing of information could lead to quicker and more effective outcomes for their clients, not just medically, but socially, financially and environmentally. One nurse said:

"There's all this integrated partnership and working together coming into place now and personally I think it's a very important thing because there's no point in me just keeping this client all to myself because I can't help him or her all by myself. " Nurse 21, G Grade

Nurses were asked if they thought the sharing of client's information between different services may deter clients from accessing treatment services. Several explained that social work and children was the big issue:

"Some of my clients are very frightened, they don't like it but I think if you are upfront with them at the start. It actually makes it a wee bit easier for you as a nurse, because you can then say there are these guidelines that we have to follow. You can't just lie and say you are not going to inform social work if you have concerns about their children." Nurse 22, G Grade

Although there were varying opinions about the effectiveness of the Joint Future Agenda, it was recognised by most nurses that there were pros and cons attached to the strategy.

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