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An exploration of the role of substance misuse nurses in Scotland

Chapter 9: Discussion and Recommendations

Reflection on methods

The aim of this study was to explore the role of the drug misuse nurse in Scotland. In order to do this a scoping exercise was first carried out to identify the study population. In such an exercise it is never possible to be certain that every relevant individual will be identified. However, in consulting a number of sources, including representatives from all Drug Action Teams throughout Scotland, the authors are confident that the vast majority of relevant services was included.

By using three different methods of data collection (postal survey, observation of consultations and nurse interviews) a greater understanding was gained than by using any one method alone. The postal survey allowed for the collection of valuable, quantifiable data across this population. With a response rate of 79% the authors feel certain that the findings of the postal survey are representative of the considerable majority of substance misuse nurses in Scotland.

Data collection by questionnaire does have its limitations however, particularly in the exploration of people's attitudes and experiences (Mason, 2002). The inclusion, therefore, of qualitative interviews provided the opportunity to explore topics and identify themes which would otherwise not have emerged by quantitative survey methods alone. Just over a third of substance misuse nurses surveyed agreed to participate in an interview. It is acknowledged this group may differ from the population as a whole. For example, in their willingness to participate, these nurses may have been more self-assured of their working methods than nurses that declined. However, efforts were made, when selecting the sample, to account for factors which may influence their views and opinions (i.e. gender, years of experience, attitudes towards working with drug misusers, and health board area).

The main purpose of the observational fieldwork was to provide a context for the nurse interviews. It is arguable that the act of being observed may have altered the usual roles taken by nurses and clients during a consultation, inducing a Hawthorne Effect (Baker, 1994). Ethical considerations require that observations must be overt in nature. Efforts were made to minimise the effects of observation by informing nurses that the researcher was not assessing the adequacy of the consultation. Furthermore, patients were made aware that they would not be identifiable.

One further issue of note was the poor recruitment of clients to the observation part of the study. This was disappointing given that clients were not the focus of the observation. Experience from nurses on the research team was that clients rarely objected to others (e.g. medical students or other nurses) sitting in on consultations. However the conditions of ethical approval were that prior notice should be given and written consent obtained. These conditions seemed to have inhibited client participation.

Description of population

Substance misuse nurses are a group of senior and experienced nurses, with 70% being G Grade or above, reflecting the responsibility of the post. Over three-quarters of these nurses had a Registered Mental Nurse (RMN) qualification as might be expected given that substance misuse medicine is based in psychiatry. However, there was still a quarter of substance misuse nurses with Registered General Nurse (RGN) training. A third were men, which is consistent with the gender ratio of CPNs generally (ISD, 2004).

Almost half of the population (48%) of specialist nurses working in drug misuse based in Substance Misuse/Drug Problem Service, a quarter in drug and alcohol services (although some Substance Misuse Services will cover alcohol as well). The remainder of the population was scattered across maternity services, social work and specialist or private clinics. Substance misuse nurses were represented in all NHS areas throughout Scotland, apart from Orkney and Shetland. (One CPN based in Orkney had a remit of alcohol problems and Shetland's community drug team had a non-nursing background).

Only 62% of substance misuse nurses had received induction training. As over 80% of those who had received it reported it beneficial, induction training should be normal practice. Formal training had been received by less than half of the respondents, consistent with previous research which has highlighted the lack of specialist training in this field (Rassool, 1996; Farmer et al., 1999). This may at first seem surprising as over 90% of nurses reported that their current job gave opportunity for ongoing training, however only 41% of nurses reported that specific time was allocated for this. If a greater proportion of substance misuse nurses are to receive formal training, protected training time may be required.

Work profile

Over half (62%) of respondents worked with general practices indicating the shared care model is reasonably widely practised. Counselling was the most frequent service provided (80%), but assessment (78%), methadone maintenance (77%) and community detoxification (72%) were all widely provided services. Further exploration of what is meant by counselling and whether this is simple information giving/exchange or whether this is based on particular models is recommended to ensure whether current training is adequate.

The median caseload was 38 with half of questionnaire respondents having between 25 and 49 cases. Surprisingly, caseload was not affected by location of the services whether city centre, urban or rural. The median number of cases seen per week was 25, but 15 nurses were seeing over 60 individuals per week. At over 12 people a day this is a high workload and it must be questioned how effective such consultations can be. The average length of a consultation was 38 minutes. Not surprisingly those with over 50 clients in their caseload were more likely to spend under 30 minutes with each client. It was notable that in the questionnaire survey, the majority reported consultation times between 16 and 45 minutes, yet in the observation of consultations, approximately half of the consultations which were scheduled for 30 minutes over ran their time by between 10 minutes to an hour. The nature of problems that substance misuse clients present with creates a tendency for consultations to over run. Both the survey and the interviews identified other impacts on quality of service that resulted from having an overstretched workload. These difficulties included not having sufficient staffing to cover holidays, training or absences due to ill health.

The large caseloads reported by some nurses indicates the substantial demand for treatment for drug misuse in Scotland. This too was reflected by waiting times when explored in the interviews. Given that the Orange Guide (D0H, 1999) advocates the stages of change model (Prochaska and Diclemente, 1986) for assessing likely successful engagement in treatment, approaching treatment at an appropriate stage of readiness is viewed as central to the success of an intervention. With this in mind, having waiting times of several weeks could mean that effective intervention points are missed.

Approach to treatment: attitudes and practice

General attitudes and approach

The questionnaire covered attitudes to the main treatment areas: maintenance prescribing and counselling. Clearly nurses were very aware of the wider social benefits of maintenance prescribing. Reducing the transmission of infectious disease, reduced problem drug use and improved mortality and morbidity were all perceived to be influential. However societal factors such as reduced crime rate and the effect on family and friends were also influential. These are rated slightly more highly by nurses than GPs. There is a role for nurses to work more closely with GPs, perhaps at a training level to widen GPs awareness of these social benefits.

In practice the majority of questionnaire respondents (84%) were expected to follow a treatment protocol. Awareness of the Orange Guide was wide with 86% having seen a copy. It is perhaps surprising and slightly concerning that this was not higher as this is probably the most important practice document to be published in this field in recent years. The majority of those that had seen the guide felt it had influenced their practice.

Nurses seemed rather more confident in their ability to provide treatment to poly-drugs users than GPs (Matheson et al., 2003). Presumably this confidence is based on positive experience. Poly drug dependence is extremely common and is even considered to be the norm. Consideration should be given to developing training for GPs based on nurses' experiences. Nurses participate in drug misuse training of doctors in Grampian already and this could be implemented in other areas.

Attitudes to particular treatments

There is now considerable evidence to support methadone maintenance treatment (Simoens et al., 2002) which was provided by three-quarters of the services in which respondents worked. Respondents believed strongly that maintenance prescribing could stop the use of street drugs. Nurses had varying degrees of influence on the starting dose of methadone and no clear pattern was evident; on the whole this seemed to be a medical decision to which the nurse could have input. However, 50 individuals wrote prescriptions for methadone which were then just signed by a doctor indicating these nurses were the chief decision maker on dose, dispensing interval and supervision. Research on the effectiveness of methadone maintenance indicates strongly that counselling increases the effectiveness of methadone maintenance (Simoens et al., 2002). Although specific questions were not asked about whether counselling accompanied prescribing, 80% of surveyed nurses explicitly said they provided counselling and from observation and interviews counselling seemed to be an integral part of consultations.

Dihydrocodeine prescribing remains a controversial issue. Dihydrocodeine is not recommended in the Orange Guide (DoH, 1999) and it is not licensed for use in managing drug dependency. However, previous research has found it is still fairly widely prescribed in Scotland by GPs (Matheson et al., 2003). Our study found that there was a reasonable proportion of nurses (40%) who believed it had advantages over methadone for maintenance for some clients. This was a considerably higher proportion than GPs (25%). Of the 50 individuals who wrote prescriptions, 20 wrote prescriptions for dihydrocodeine. The majority of those writing prescriptions for dihydrocodeine were based in Lothian where there is a history of dihydrocodeine prescribing and a randomised controlled trial of dihydrocodeine versus methadone is nearing completion. Results of this study (available 2005) should allow clear recommendations on future practice.

Previous research has found that 43% of GPs believed that detoxification programmes are always preferable to maintenance programmes (Matheson et al., 2003). Nurses were found to be less in favour of detoxification over maintenance (only 6% believed it to be 'always preferable') although over three quarters felt a community based detoxification programme was an effective tool in treatment. Thus it seems to be considered a useful option for some people. This is in line with clinical guidelines (DOH, 1999) and the body of evidence which suggests the effectiveness of detoxification programmes is limited (Simoens et al., 2002). However, there did seem to be a strong belief that opiate withdrawal should be followed by a period of rehabilitation.

Attitudes to drug misusers

Not surprisingly, the vast majority of nurses was sympathetic towards drug misusers. They were found to be more sympathetic than pharmacists, GPs and, from previous research, they have more positive views than general nurses and those working in the prison system (Carroll, 1995). GPs and pharmacists displayed very similar responses when asked whether they agreed or disagreed with the statement "I have no sympathy at all for drug misusers" with approximately 70% disagreeing. The difference between their responses and those from nurses is in the strength of response with 98% either disagreeing (27%) or strongly disagreeing (71%).

The majority of nurses had positive attitudes to drug misusers before they worked in this field. Often it was the view that this would be a challenging and enjoyable group to work with that motivated them to move into this area of work.

Thus whilst other generalist health professionals who are involved in drug misuse services may display a degree of sympathy, many are happy for someone else to manage this group. For example over 60% of GPs feel drug misusers should only be seen by specialist services (Matheson et al., 2003) and almost 40% of pharmacists believe drugs should be dispensed through a central clinic rather than community pharmacies (Matheson et al., 2002). Pharmacists and GPs consider drug misusers to be a challenging group who take up a lot of time and are disruptive to other patients (McKeown et al., 2003; Matheson, 1998). Nurses working with drug misusers seem to view drug misusers as a challenging group in a more positive way. Few considered drug misusers to be an easy group to deal with yet 75% considered working with drug misusers to be rewarding. Perhaps the greater challenge means there is a greater reward or feeling of achievement when positive results are seen. GPs and pharmacists are generalists and their views are likely to be dependent on how they compare drug misusers to other groups of patients. Whereas nurses, as specialists, have no such comparisons to make.

Relationships with other professionals

The Orange Guide (DoH, 1999) advocates a shared care approach to drug misuser management involving, as appropriate, a broad range of health and social care professionals. Nurses reported a high level of communication with other professionals. Presumably this has positive implications for patient care. There were some areas requiring improvement. Nurses seemed particularly dissatisfied with the level of communication they had with policy makers with 70% of nurses viewing the level of communication they had as being insufficient. Better representation of substance misuse nurses on DATs may be one way of increasing their involvement. Given that a high proportion of nurses in the questionnaire felt local services did not meet the needs of drug users, the input of nurses at local service development level seems crucial. Perhaps DATs should have a local nurse representative who is largely involved in patient care (as opposed to managerial level).

The questionnaire survey indicated that substance misuse nurses generally felt they had a good working relationship with GPs. This was further demonstrated in the nurse interviews where good working relationships were associated with GPs valuing the skills and knowledge that substance misuse nurses brought to the service. Previous studies have shown GPs to lack confidence and knowledge of treatments, (McGillion et al., 2000, Matheson et al., 2003) so this may be why they value working with substance misuse nurses.

Although nurses reported having the opportunity for discussion with social workers, interviews with nurses revealed some discontentment among nurses on working arrangements with social work departments indicating that links could be improved.

Shared Care to Integrated Care

From questionnaire responses it was clear the majority of nurses was positive about a shared-care approach; for example approximately 70% agreed that drug misusers should be referred back to their GP when they had been stabilised and only 16% agreed that drug misusers should only be seen by specialist services. Nurses generally have a high level of input at general practice level indicating some form of shared care is widely practiced. However no clear pattern is evident in the delineation of tasks between general practitioners and nurses within shared care models. This is corroborated by previous research which found GPs input into shared care to be very variable (Graftham et al., 2004). Thus it appears that GPs contribute as much into patient care as they can or wish and nurses do the rest. However, the implementation of GP contracts will clarify the tasks required of GPs.

Interviews were conducted at the time Integrated Care Services were becoming a topical area for development and discussion. Thus this subject was raised in pilot interviews and it was considered important to include in the interview schedule. Some interviewees were still fairly uninformed about plans for Integrated Care Services indicating a need to raise awareness. Among those who were more informed concerns were raised about the relevance of sharing information. This concern has been acknowledged in the Effective Interventions Unit (EIU) publication on Integrated Care (Integrated Care for Drug Users, 2002) yet still may be an issue for front-line workers. A particular area of concern is in sharing information with social work because of implications perceived by clients for child custody. (Note that guidelines on this are widely available (Scottish Executive, 2001)). However, the main concern raised was with the relevance and size of assessment tools to allow it to apply to all agencies. Joint assessment tools could overcome the problem of inconsistent information being available to substance misuse nurses from referrals as highlighted in this study.

A basic principle of the Joint Future Agenda is that services should be client focussed. Integrated Drug services are being developed to overcome problems for clients who have to always give the same information to different services. This intended benefit of Integrated service was not referred to by any of the nurses interviewed. Consequently, there is a need to keep nurses more aware of developments in this area and the principles behind these service developments.

Decision making and autonomy in practice

This research was initiated by the hypothesis that nurses working with drug misusers had a pivotal role in the care of those drug misusers. It was speculated that nurses had a relatively high degree of autonomy compared to other areas of practice. Previous research with GPs had highlighted the high profile of nurses and demonstrated that GPs may rely heavily on their specialist nursing colleagues.

In fact the issue of autonomy is not straightforward. Many substance misuse nurses work in some isolation from their service colleagues particularly those whose clinics are largely based in GPs surgeries or, less frequently, those conducting home visits. There is an apparently high level of discussion with service colleagues which provides support. Support is also provided by the use of service protocols/guidelines which are the norm. Decisions such as starting doses, of methadone, for example are either a medical decision or are determined within a protocol so clinical decision making in this respect is limited. Even in cases where the prescription is written by the nurse and signed by a GP, the dose, dispensing interval and dispensing conditions (i.e. whether supervised) is generally covered within protocols.

The issue arising from the evidence that nurses sometimes write prescriptions to be signed by GPs is that of clinical responsibility/governance. In signing the prescription a GP is taking responsibility even though s/he may know little about the patient's current condition. Fewer than a third of questionnaire respondents (27%) felt writing and signing prescriptions was a medical responsibility not a nursing responsibility. There is a willingness to take on this role if it is limited to very experienced nurses with appropriate training. Although some nurses can prescribe certain items at present this does not include controlled drugs although this might soon be possible under the supplementary prescriber scheme (NHS Scotland, 2003). Nurse prescribing is a developing area and as part of the strategic development of this area prescribing of a very limited range of drugs, including controlled drugs, by suitably trained substance misuse nurses should be seriously considered so that they can accept fully informed responsibility for client prescriptions.

The level of autonomy is more evident in nurses' role in reaching the decision about what treatment approach to take e.g. maintenance or detoxification. Findings indicated decisions regarding treatment plans were made largely between nurses and clients with one other health or social care professional commonly being consulted before settling on a treatment plan. Approximately half of nurses consulted medical staff, whether a GP or consultant. Protocols are used less in this decision making process regarding treatment plan. Thus the role of the nurse in this initial assessment and treatment plan is critical. It was clear that a considerable number of factors, both patient related and societal, have an influence on the majority of nurses. Not surprisingly, in terms of patient factors, pregnancy had the greatest influence. The strongest societal factor in influencing treatment decisions was the potential that drug treatment has in reducing transmission of infectious diseases. The broad range of factors which influenced the majority of nurses highlights the complex range of issues considered when making treatment decisions.

The other main strand of a substance misuse nurse's practice is ongoing support or counselling. The nature or model of this counselling was not explicitly covered in the questionnaire or interview section of this research. However, from observation this was evident. A study evaluating and comparing the cost effectiveness and outcomes of different models of counselling would be an area for future research.

Some may question whether a nurse is necessary for these tasks that define their current role. From this data it is clear that in the initial assessment discussion of medical complications and some degree of medical examination is essential. A nurse may not be essential for ongoing support and counselling which, from observational data, appears to focus more on social and personal aspects of their drug use or life in general. However, medical complications may still arise and there is often some discussion of their ongoing treatment, the dose of medication etc for which some pharmacological knowledge is necessary.

The range and variation in job titles does not reflect at a national level the core elements of practice undertaken by this group. This may undermine their input in policy and practice whether at DAT level or Scottish Executive because they are not defined and thus clearly representable.

Health and safety issues

Stress

In the present research it was notable that a tenth of nurses had either left their post or were on long-term leave for ill health reasons at the time the questionnaire survey was disseminated. Similarly, at the time when the nurse interviews were being arranged, a further 10% were not available due to 4% being signed off work 'long term' and 6% no longer working for the service/agency they had been originally identified in. Both a high turnover of staff and sickness absence have been associated with stress and emotional exhaustion (Firth and Britton, 1989), consequently stress is considered to have a considerable impact on substance misuse nurses.

In identifying what causes stress, many nurses interviewed emphasised that it was not so much the direct contact with patients that was the cause of their stress but other aspects such as paperwork, caseloads and working in isolation. This corresponds with other research which has aimed to identify the stress factors in nursing. A number of studies focusing on psychiatric nurses have acknowledged that the stress of undertaking administrative requirements may be more stressful than direct patient care (Sullivan, 1993; Ryan and Quayle 1999; Hannigan et al., 2000). Also emerging from the nurse interviews, holiday periods were identified as a difficult time which impacted on workload as there was insufficient cover. The observed levels of sickness and turnover of staff in conducting this research must also impact on their stress levels, as well as compromising quality of care. This is consistent with research which has focused on general nurses and found that covering for absent colleagues has been identified as one of a number of stressors they experience (Fitter, 1987).

Factors were identified on how stress was reduced and managed. Team support was seen to help reduce the impact of stress and supervision was identified as having a valued role in this. Other studies have shown nurses to value the provision of clinical supervision (Scanlon and Weir, 1997; Palsson et al., 1996). The nurses in this study also emphasised the value of informal support provided by others in their team. Despite this, the nature of the work, requiring movement around different locations, often meant these nurses felt isolated and this contributed to their stress.

This study identified elements of substance misuse nurses' work which could be part of the causes of stress and therefore should be addressed. In the interviews, nurses' caseloads emerged as a contributor to stress, particularly when colleagues were absent and pressure on remaining nurses increased. Also, in the questionnaire survey, almost two-thirds of nurses reported that their current caseload was larger than ideal. Furthermore, nurses with caseloads of over 50 patients reported shorter consultation times. It would seem that by increasing the numbers of nurses working in this field issues of occupational stress and quality of service could be jointly addressed.

Safety at work

Previous research has indicated that the workplace can be a particularly dangerous place for nurses (Farrell, 1999; Dalphond et al., 2000). Substance misuse nurses may be especially at risk due to the nature of the vulnerability of the patient group they work with; due to their work being community based, lone visits may be required to be made to patients in their homes. A considerable proportion of the nurses surveyed (64%) had experienced physical or verbal threats from patients. This level of threat is certainly a concern. The finding that over half of respondents did not think they were adequately protected should a threatening incident occur highlighted the inadequacy of safety provisions in some settings. The need to provide safety procedures to protect nurses has been a focus of the Community and District Nursing Association (CDNA). The CDNA campaigned for all community based nurses to be provided by their employer with appropriate training, procedures and practices to allow them to carry out their work safely. It was clear from interviews that nurses' experiences of such procedures varied widely. Where such procedures existed, they were not always implemented. These findings suggest that employers in all work settings where substance misuse nurses are based should be reassessing the protection and safety procedures they have in place in order to better protect nurses. Some interviewees relied on their common sense and intuition. This itself does not amount to adequate safety provision.

Conclusions and Practice Implications

This research has been largely descriptive in nature, providing an overview of the role of substance misuse nurses in Scotland. This research highlights the seniority of this group of nurses in terms of grade and age. Many of these nurses are clearly confident in their practice and feel able to work in relative isolation, if not necessarily independently. There is clearly a consistency of approach to managing drug misusers across NHS areas which is reassuring.

Our research has identified a number of implications for future practice. An important consideration lies in the role of the substance misuse nurse in prescribing and whether the present responsibility of senior, experienced nurses should be extended to signing prescriptions. As substance misuse nurses expressed greater confidence than GPs in working with poly drug users, an opportunity exists for nurses to work closer with GPs to provide support and help develop GPs' confidence in working in this area. Safety procedures may need review in some areas. Furthermore, appointment scheduling may need review as there was evidence that consultation time was routinely underestimated. However, it is acknowledged other problems such as frequency of missed appointments need to be considered at the same time.

This research has also raised other questions that may need further investigation through further research or local review. Particularly the tools used in assessment may need consideration at local level. There was some evidence from interviews that SMR24 monitoring forms were being used as an integral part of the assessment. An SMR24 form must be completed but this is not an assessment tool and does not allow for ongoing assessment. However as this study was not aimed at exploring assessment tools per se further clarification is suggested at local level. This could be considered in line with local development of joint assessment tools under the strategic development of integrated care for drug users. Similarly further investigation of counselling models used in practice may be beneficial.

Finally, this study highlighted the lack of clarity and consistence of job titles which is considered to add to the lack of professional identity of this group at a national level. This issue is also currently being considered by the Nursing and Midwifery Council. Greater clarity of role and recognition of this by more inclusion of substance misuse nurses (not just service managers) at local policy level would give this group greater recognition of the important role they play.

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