Presenter Information

Audrey KillarneyFollow

Start Date

18-8-2017 10:00 AM

End Date

18-8-2017 11:30 AM

Description

Clinicians’ perspectives and utilization regarding harm reduction in nursing practice in care of persons with addiction: A literature review

Audrey Killarney, BS

Prof. Michelle Neuman, MSN, APN, RN

NSG 598: Graduate Research Synthesis

18 August 2017

Introduction

Background & Significance

Harm reduction is a concept best described as the recognition that individuals will engage in unhealthy behaviors, and the goal is to minimize the associated potential harm. (Stockwell, Reist, Macdonald, Benoit, & Jansson, 2010). Classically, it was used an alternative model of care for treating smokers and controlling the spread of HIV and hepatitis B (Henwood, Padgett, & Tiderington, 2014). However, in the context of medicine, harm reduction allows the clinician to accept that the patient may continue a harmful behavior, and their duty as a clinician is to minimize the relative risks and harms associated with that behavior (Öztuna et al., 2014). Most recently, harm reduction has been introduced as a means to address treatment for persons with addiction (Aldridge, 2012). These patients carry complex medical and social histories, for which traditional “treatment first” approaches may not be appropriate (Henwood et al., 2014). For example, Draanen et al. (2013) found an associated mental disorder in over 1/3 of patients who abuse alcohol, and over half of patients who abuse drugs. This finding supports the hypothesis that patients with severe mental illness often self-medicate with drugs and/or alcohol to control their psychosis (Henwood et al., 2014).

Previous studies have consistently reported that patients with addiction are more likely to be immune-compromised and have poor nutritional status, which can greatly affect their response to medical treatment (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013). These individuals are also more likely to delay seeking medical treatment for acute issues, resulting in hospital visits for far more severe and advanced illnesses (Ford, Bammer, & Becker, 2008). Harm reduction allows for clinicians to assess other aspects of a patient’s well-being, such as secure housing, employment, and social support, which may contribute to recovery and/or relapse (Henwood et al., 2014).

Harm reduction holds great significance in current nursing practice given the recent rise of substance abuse and overdose deaths in the United States. In 2014, it was estimated that abuse of tobacco, alcohol and drugs cost the United States over $700 billion in loss of productivity, healthcare, and crime (National Institute on Drug Abuse, 2015). These numbers are significant, as harm reduction interventions in Canada have been able to alleviate hospital-based costs, reduce ED visits, as well as reduce overnight hospital stays (Draanen et al., 2013). A growing problem in the United States surrounds the epidemic of opioid overdose. Heroin overdoses account for the fastest growing group of overdose deaths, with a 6-fold rise over the period of 2001-2013 (National Institute on Drug Abuse, 2015). In response to rising heroin overdose rates, overdose education and naloxone distribution (OEND) programs are increasing nationwide. These types of programs are commonly sponsored by the Harm Reduction Coalition, as they seek to reduce potential risks and mortality associated with drug use. This finding further supports the argument for inclusion of harm reduction in the care of persons with addiction (Lewis et al., 2016).

Nurses in particular, are positioned to experience situations in which harm reduction strategies may be appropriate. Nursing staff are frequently involved in patient education, and re-education, of hospitalized patients; while an individual may not be ready to receive treatment, nursing staff could be qualified to provide information regarding self-help groups (Bartlett et al., 2013). Additionally, nurses conduct many of the initial screenings during hospitalization; these screenings include alcohol and drug abuse questionnaires that provide a bridge to discussions regarding use and healthy use of alcohol, prescription drugs and illicit substances (Bartlett et al., 2013). Furthermore, nursing practice acts in a few states including North Carolina, New York, and California, allow for nurses to conduct counseling on reducing the adverse effects of a patient’s addiction. However, little information is readily available about the implications of nursing staff utilizing harm reduction in the United States (Bartlett et al., 2013).

Purpose

The purpose of this integrative literature review was to identify how nursing practice can utilize harm reduction in the care of persons with addiction. This review examined the use of harm reduction for addiction patients and its efficacy. Additionally, the review focused on studies in which clinicians offer their perspectives and attitudes towards harm reduction.

Research Questions

  1. What are clinicians’ perspectives regarding use of harm reduction strategies in the care of persons with addiction?
  2. Which practices are employed to ensure successful harm reduction utilization in care of persons with addiction?

Conceptual Model/Theoretical Approach

The conceptual model most appropriate for this study was Pender’s Health Promotion Model (HPM). Originally developed in 1982, Pender’s theory views the patient as a holistic being requiring a multidisciplinary approach to health (Alkhalaileh, Khaled, Baker, & Bond, 2011). A revised version of model map is attached in Appendix A. Key assumptions of the HPM include that individuals have the ability for self-awareness, they have the desire to regulate their own behavior, and that health professionals are a part of the interpersonal environment which carries the potential to influence patient behavior towards their health (Alligood, 2013). Pender identified 14 theoretical assertions to describe the HPM; of those, 3 assertions were identified as correlating with harm reduction:

“3. Perceived barriers can constrain the commitment to action, the mediator of behavior, and the actual behavior…

7. When positive emotions or affect is associated with a behavior, the probability of commitment and action is increased…

13. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention,” (Alligood, 2013, p. 403).

Pender’s model aligns well with the harm reduction approach as one of the key tenants of harm reduction, is the recognition that individuals possess autonomy over decisions related to their health care (Szott, 2015). Additionally, harm reduction addresses the holistic factors that contribute to the ultimate goals of sobriety: education, employment, housing, co-morbidities, and stress management. Harm reduction also places emphasis on gradually creating new behaviors as a means to prevent relapse (Bradbury-Golas, 2013).

Methods

Design

This study employed an integrative literature review to assess how, if at all, harm reduction has been integrated into nursing practice. Integrative literature reviews can be especially helpful to analyze new or emerging topics in a given field (Torraco, 2005). An integrative literature review allows for a holistic approach to gathering information regarding the topic given that the topic of harm reduction in nursing is relatively underdeveloped. Additionally, integrative literature reviews can synthesize the various literature, in order to produce a clearer picture of the phenomenon or research question (Torraco, 2005).

Literature Search Strategies

In order to acquire literature for this integrative literature review, the following databases were used: CINAHL complete, PubMed, and ProQuest Nursing and Allied Health Source. The following search terms used were as follows: “harm reduction & nurs*,” and “harm reduction & addiction,”.

Inclusion & Exclusion Criteria

Articles were selected if they were in English, published within the last 10 years (2006-2016), published in an academic peer-reviewed journal, and were primary sources. Literature was analyzed if the focus included the following topics: current harm reduction strategies, clinician perception of harm reduction, nursing care of persons with addiction, treatment centers that employ a harm reduction approach, and nursing position pieces on harm reduction. Of the 99 articles retrieved, 10 were analyzed in the integrative literature review. The remaining 89 articles were excluded due to the following parameters: duplicate article, application of harm reduction to alternative health disparities (fall prevention, smoking cessation, or cardiovascular disease), no clear relationship to nursing practice, or a position piece. The articles chosen for review are outlined in more detail in the included research matrix (Appendix B).

Results

Results of the integrative literature review yielded 4 articles regarding clinicians’ perspectives on harm reduction use, and 6 articles regarding current use of harm reduction in nursing practice. Selected literature was rated using the Melnyk Fineout-Overholt Hierarchy of Evidence (2011) (Appendix C). Analysis of the literature regarding clinicians perspectives on harm reduction use revealed common themes such as: consistency with nursing ethics; harm reduction as honoring a patient’s autonomy; and socio-cultural challenges related to harm reduction use. Literature regarding current use of harm reduction revealed themes such as: harm reduction’s ability to address the patient as a holistic being; nursing’s role as patient advocate; and harm reduction as a bridge to abstinence.

Clinician’s Perspectives on Harm Reduction Use

Nursing Ethics. A region’s specific nursing code of ethics can often be interpreted as aligning with the tenants of harm reduction. The Canadian Code of Ethics for Nurses states "that nurses have a responsibility to provide 'persons in their care with the information they need to make informed decisions related to their health and well-being.' " (Lightfoot, 2009, p.21). This responsibility and duty does not preclude drug abuse and misuse. The Canadian Nurses’ Association has published a position piece as a means to gain greater acceptance of harm reduction in the workplace. They describe, in detail a well-known harm reduction facility known as “Insite” which provides counseling, needle-exchange "The practice of its nurses is guided by core principles of harm reduction and health promotion that are central to achieving Insite's objectives and consistent with professional ethical standards." (Lightfoot, 2009, p.21)

Patient Autonomy. An important tenant of both harm reduction and nursing ethics is patient autonomy. Many studies cited historical roots of paternalism in treating patients with addiction; however, harm reduction reflects “…a client-centered philosophy and a recovery orientation where clients are driving goal setting and where care plans are based on clients’ strengths and choices,” (Drannen, 2013, p.534). This is impactful in that clients are able to take ownership of their recovery, increasing the likelihood that they will succeed. Additionally, many studies citing usage of harm reduction cautioned clinicians towards directing a patient to recovery as it may foster feelings of resentment and resistance. The shifting of responsibility of recovery from clinician to patient also alleviated a great deal of stress from the clinician in that it was not their personal goal that needed to be achieved.

Socio-cultural challenges. While there were many studies in support of harm reduction, it was not met without criticism or skepticism by clinicians working in drug-free treatment centers. Clinicians cited that a harm reduction approach would be in direct contradiction to their program and recovery model. Many clinicians also expressed fear of legal action or loss of license. Clinicians working in methadone maintenance facilities and safe needle exchange facilities in the U.S., cited greater issues with accessing affordable and subsidized housing for clients, that was not contingent upon abstinence. Studies coming from European countries cited harm reduction’s alliance with the EU’s policy that individuals with addiction have the right and ability to take ownership of their recovery (Gray, 2014, p.39). Even with support from governmental authorities and nursing bodies, most studies continued to acknowledge the disparities and prejudice addicts face in society; this prejudice can be alienating to an addict and prolong the time to seek treatment.

Current Use of Harm Reduction in Nursing Practice

Holistic care. Several harm reduction programs and interventions exist in Canada to address their specific substance abuse problems. Toronto is unique in that it has created a case management program designed to intercept individuals before reaching the emergency department, and connect them to social services of which they’re eligible. The Toronto Community Addictions Team (TCAT) is a program that “…aims to create a model of care that includes the promotion of empowerment, respect, and dignity, ensuring services are delivered in the least restrictive, intrusive, and stigmatizing ways,” (Drannen, 2013, p.534). An important component of harm reduction is its ability to connect clients with social services. Persons suffering from addiction often experience a variety of social challenges ranging from housing insecurity, mental illness and lack of financial management; programs like TCAT seek to address the person as a holistic being, and seek to correct factors that may contribute to relapse. Additionally, clients develop trusting relationships with clinicians in harm reduction facilities, thus engaging and retaining them in social services.

Advocacy. Advocacy, and the nurse as advocate, were described in a variety of settings. The Canadian Nurses’ association urges all nurses to educate themselves in harm reduction practices; they state, "all nurses should be well informed about harm reduction interventions and their place in the preventions, care and treatment continuum, so that they can humanely care for those who use drugs by referring to and advocating for all types of evidenced-based addiction supports," (Lightfoot, 2009, p.21). In settings utilizing harm reduction, clients expressed favorable feelings towards having someone whom they felt could speak on their behalf, and had their best interests in mind. This is especially important for patients who harbored distrust towards healthcare professionals. Clients also expressed gratitude at having someone with whom they trusted able to manage their finances. Having a safe and secure place in which to keep their money reduced fear that they may be robbed. Clients were also grateful to be able to see progress towards financial security; this was evident in greater money saved on a weekly basis, and less money spent on drugs and alcohol. Advocacy can also be interpreted from the perspective of nursing policies and drug enforcement laws. Nurses hold positions of influence in both their local, state, and federal governments; they serve as liaisons to legislators who may not be familiar with the current state of healthcare. In regions unfavorable to addicts, “action on drug policy reform must be part of a broader agenda to enhance social justice that seeks to take action on the underlying conditions that produce poor health such as homelessness, violence, poverty, and racism," (Pauly, 2007, p.22).

Bridge to abstinence. One of harm reduction’s key tenants relies on the understanding and assumption, that a patient may continue to use or abuse substances during their treatment. Several studies have suggested harm reduction’s ability to serve as a bridge to abstinence, rather than an alternative to abstinence. An ethnography qualitative research study of addiction nurses in France offers this perspective of their work: “I always insist on not making things go smoothly for the patients. The treatment framework is in place to be transgressed…. Transgression is the essence of therapy,” (Gray, 2014, p.37). While this idea may seem counterintuitive to the traditional medical model, in which clinicians facilitate recovery, it reflects a realist mentality common in harm reduction practices. Additionally, it removes the shame and guilt often associated with relapse. Clinicians described relief when clients were open and honest about their relapses; this honesty allowed them to continue a relationship based on trust and mutual respect. Studies regarding current use of harm reduction regularly state that abstinence is not a requirement for treatment, and clients take responsibility for directing the pace of recovery. Goals of German harm reduction programs are, “to stabilize the drug addict's health status and gradually move them toward abstinence." (Michels, 2012, p.917)

Discussion

Clinician perspectives of harm reduction revealed a view of harm reduction as honoring a patient as a holistic being, and ability to serve as a better advocate. While still acting as an advocate, clinicians felt they were better able to honor a patient’s autonomy in decision-making. Patient autonomy, and trust in a patient’s ability to make health related decisions, is one of the key tenants of Pender’s Health Promotion Model; both perceived self-efficacy and perceived barriers to action greatly influence a patient’s commitment to action, and ultimately the adoption of a health promoting behavior. Studies regarding current use of harm reduction found positive results in patients’ self-reported advocacy, self-esteem, and ability to navigate social services. Patients also experienced a decrease in problems associated with drug and alcohol use, as well as a decrease in money spent on drugs or alcohol.

In addition to the evidence-based successes, the ethical components of harm reduction align with much of the nursing code of ethics. When looking towards gaining “buy-in” from American nursing executives, this will be especially useful. The nursing code of ethics largely guides individual states’ nurse practice acts. While several states have allowed for special considerations for nurses desiring to practice harm reduction, there is much work to be done to gain approval across the rest of the country. On the individual level, there are best practices that a nurse can employ to incorporate harm reduction into their everyday practice regardless of the setting in which they work. They exist on a hierarchy from the immediate level (treating drug users with dignity and autonomy) to a government level (advocating for policy changes to decriminalize users). The model is further described in a theoretical model (Appendix D).

Limitations

Limitations of this integrative literature review included the limited studies in the United States, few quantitative studies, and few studies from well-known and reviewed journals. Limitations of this studied also included few studies directly related to nursing. Many of the studies came from drug treatment facilities with nurses, as well as physicians and social workers on staff.

Direction for Future Research

Future steps for this research would include surveying nurses of a variety of hospitals in an urban setting regarding their knowledge and feelings towards harm reduction. The information garnered from these surveys would allow researchers to objectively quantify and qualify the level of nursing knowledge, to formulate impactful and appropriate nursing education in their institution. A recent pilot study from Massachusetts General Hospital identified a deficit in professional nurses’ confidence and preparedness in caring for persons with substance use disorders (SUD); results of the pilot study found nursing attitudes towards persons with SUD’s to be more positive following a 6-month training program for the CARN (Certified Additions Registered Nurse) exam (Parhiala, J. & Quinn, P., 2017). A similar single site study could be performed to first assess attitudes and confidence in nurses regarding caring for persons with SUD’s, in order to formulate an appropriate intervention for clinicians.

Nursing Implications

As aforementioned, nurses are perfectly poised to both identify patients in need of harm reduction strategies, as well as incorporate basic harm reduction techniques into their care. Nurses are also at the front-line of patient-centered care, and serve as examples to other healthcare staff on patient-centeredness. Additionally, nurses must be aware of the attitudes and beliefs of fellow clinicians towards persons with addiction

Conclusions

This integrative literature review provided a great deal of information regarding clinician perspectives of harm reduction and a few isolated studies of current use of harm reduction in clinical practice. Given the rapidly increasing rates of drug abuse and overdose, it would behoove facilities to train all registered nurses, regardless of their specialty, in basic knowledge of addiction and treatment options.

Appendix A.

Appendix B.

Citation

Phenomenon

& Research Question

Design, Methodology

& Analysis

Population

Results/

Findings

Critique/

Evaluation

Thematic Category

Draanen, J. v., Corneau, S., Henderson, T., Quastel, A., Griller, R., & Stergiopoulos, V. (2013). Reducing Service and Substance Use Among Frequent Service Users: A Brief Report From the Toronto Community Addictions Team. Substance Use & Misuse, 48(7), 532-538.

Examine the efficacy of an intensive case management team (TCAT) serving substance abusers with high healthcare utilization.

Both qualitative and quantitative methods were employed. Semi-structured interviews were performed with 10 male clients, 9 months after enrollment in the program. Interviews were transcribed and analyzed using “thematic analysis”. Measurable changes were identified using quantitative methods with validated tools such as the Multnomah Community Ability Scale (MCAS) & the Addiction Severity Index (ASI). Results were analyzed using a paired t-test and SPSS software.

Adult, substance abusers in the Toronto area, enrolled in the TCAT (Toronto Community Addictions Team).

Qualitative: Participants identified themes of advocacy, trusteeship, navigation, access and support; almost every participant spoke of the importance of having someone to talk to.

Quantitative: 43% of participants identified a corresponding mental illness, 90% were unemployed, and 55% had a history of family substance abuse. Clients decreased their withdrawal management services use significantly after 12 months of follow-up.

Dedicated case management teams, along with social support and non-judgmental treatment attitudes contribute to better continuity of care and outcomes for patients.

Case management

Harm Reduction Efficacy

Service Usage

Eversman, M. (2012). Harm reduction practices in outpatient drug-free substance abuse settings. Journal of Substance Use, 17(2), 150-162.

Drug-free/non-drug substitution treatment practices have been cited as hindering utilization and retention of substance abusers. While harm reduction is an alternative approach, little is known about providers’ views.

Qualitive study, conducted using semi-structured interviews of healthcare providers in substance abuse settings. Interviews were audio recorded, transcribed, and analyzed using Atlas TI software for meaningful quotations and themes.

Front-line practitioners in outpatient drug-free facilities within a 50-mile radius of a “medium-sized Northwestern US city”.

Support for practices such as tapering plans, non-abstinence treatment goals and substance use management was limited. However, respondents reported generally being in favor of the idea of “harm reduction philosophy”.

While there is support for harm reduction, the study did a generally good job of identifying agency practices & policies that are likely to conflict with harm reduction.

Clinician perspectives

Agency policy

Conflicting treatment ideologies

Harm reduction as a guiding principle.

Gray, M. T. (2014). Agency and Addiction in a Harm Reduction Paradigm: French Nurses' Perspectives. Archives of psychiatric nursing, 28(1), 35-42.

Psychiatric nurses possess a unique perspective on the treatment of individuals with addiction. Their challenges, beliefs, and practices are largely unknown in the EU.

Ethnography, a type of qualitative research, was employed. The researcher lived in the south of France for 5 months as part of an immersion experience. Two psych hospital directors were contacted, and they were able to provide nurses for interviews. Semi-structured interviews were performed, translated into English, coded and analyzed for themes and key words/phrases.

French psychiatric nurses in the south of France.

Nurses identified themes: agency (individuals’ autonomy), boundary setting, effective therapy.

Nurses raised important concerns about maintaining a patients’ ability to choose. Additionally, they provided insight on navigating the complicated nurse-patient relationship. Reiterated idea that addiction is a global phenomenon.

Efficacy

Ethics: Autonomy

Henwood, B. F., Padgett, D. K., & Tiderington, E. (2014). Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. The journal of behavioral health services & research, 41(1), 80-89.

Housing services for displaced individuals are typically drug-free, or post-substance abuse treatment. Analyzes provider views of harm reduction practices/abstinence in working with patients who have experienced homelessness.

Multiple in-depth interviews with 41 providers dually enrolled in the “New York Services Study”, a longitudinal study. 20 providers were members of the “housing first” group, and 21 providers in the “treatment first” group. Thematic analysis employed with ATLAS.ti software.

41 front-line providers working in homeless services in New York, whose patients were enrolled in the NYSS.

Identified themes such as a “welcomed alternative”, working with ambiguity, accommodating abstinence.

Strong study in that it included providers from both settings. Brings to light many of co-existing social issues compounded by substance abuse. Maintains a stance that the housing first model can integrate abstinence. Harm reduction exists on a continuum of practices.

Application of Harm reduction

Clinician views

Social implications

Lewis, D. A., Ju Nyeong, P., Vail, L., Sine, M., Welsh, C., & Sherman, S. G. (2016). Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition. American Journal of Public Health, 106(7), 1243-1246.

Overdose education and naloxone distribution (OEND) programs are often targeted at opioid users. However, states are now passing laws to educate and train third-party individuals on overdose prevention & naloxone administration.

Longitudinal study consisting of pre/post training surveys & follow-up surveys conducted over the phone. Participants took part in an OEND program conducted by Baltimore Student Harm Reduction Coalition. Data analyzed using McNemar test in Stata software.

Individuals >18y/o in Maryland

Statistically significant increase in knowledge about overdose, and ability to help in the instance of an overdose. No shift in perception of criminal implication from law enforcement. 86% of participants on follow-up surveys states they had told others they were trained and had naloxone. 3 participants reported overdose reversal, & 2 cases reported a parent unsuccessfully being able to reverse overdose.

In just 8 months, a student run organization could train 285 individuals in overdose and naloxone administration, resulting in 3 successful reversals of overdose. Speaks to public’s need and desire for greater education on overdose and naloxone.

Application of harm reduction

Efficacy

Public desire

Lightfoot, B., Panacea, C., Hayden, S., Thumath, M., Goldstone, I., & Pauly, B. (2009). Gaining Insite: Harm reduction in nursing practice. Canadian Nurse, 105(4), 16-22.

Insite, a supervised injection facility in Vancouver, has been shown to increase referrals, reduce the spread of blood-borne pathogens, and prevent overdose deaths. What is not well documented is how nursing practice coexists with harm reduction.

Editorial/position piece. Outlined past/present objectives of the organization. Cited numerous studies documenting efficacy of Insite.

N/A

Insite serves the community in several ways: relationship building, primary nursing care, education and partnership with other health and social systems.

The benefits of Insite are well documented and carry a great deal of support from a variety of studies. All nurses should be familiar with the continuum of: prevention, care and treatment.

Efficacy

Application of Harm Reduction

Intersection with Nursing Practice

Michels, I. I., & Stöver, H. (2012). Harm reduction—From a conceptual framework to practical experience: The example of Germany. Substance use & misuse, 47(8-9), 910-922.

Drug abuse is on the rise globally, and even through modern approaches to control the spread of blood borne diseases, HIV infections are on the rise globally. A comprehensive approach must be undertaken. The writers use the example of Germany to undertake this goal.

Systematic literature review of history of harm reduction and approaches to substance abuse in Germany.

N/A

Germany has a history of harm reduction measures dating back to the 1970’s. They include: opiate substitution treatment, syringe/needle exchange programs, drug consumption rooms, medical assisted treatment and heroin assisted treatment.

Overall, Germany has a vast history of harm reduction techniques used. They provide a framework for other European and western nations.

Efficacy

Intersection with Nursing Practice

Application of Harm Reduction

Policy/Practice

Pauly, B. B., Goldstone, I., McCall, J., Gold, F., & Payne, S. (2007). The ethical, legal and social context of harm reduction. Canadian Nurse, 103(8).

There is a large amount of literature regarding evidence-based practice of harm reduction; however, for successful integration, there must be “buy-in” from the ethical standpoint as well.

Case study/descriptive study of healthcare policy

Canadian nursing association (CNA)

Provides examples of harm reduction at play in many of the outlined principles in the Canadian Nursing Code of Ethics. Additional support from stakeholders in nursing and medicine.

This review did a nice job of touching on the different ethical principles in the code of ethics, and relating them back to harm reduction. However, this piece of literature would be more valuable if it were able to be compared to the American Nursing Code of Ethics.

Harm reduction in nursing practice

Ethical implications

Public desire

Szott, K. (2015). Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine, 19(5), 507-522.

The concept of addiction as a disease and harm reduction are in stark contrast to the traditional approaches of medicine. While these practices may begin to become commonplace in current medicine, provider adoption depends largely on perception.

Semi structured qualitative interviews with 13 health care providers in NY. Transcripts were coded and themes related to “harm reduction” were identified. HyperRESEARCH data software was used for analysis.

13 health care providers in NYC who provide primary care or buprenorphine/methadone treatment to people who inject drugs.

Providers identified harm reduction techniques they already use, they spoke to the comparison of addiction as a disease to both aid in their treatment of patients and patients’ acceptance of their disease process.

While the themes and discussions are valuable and interesting, the sampling of providers is in an area so specific to treating injection drug users, that they may not be representative of the general population of medical providers.

Harm reduction application

Clinician view of harm reduction

Ethical implications

Appendix C.

Melnyk Fineout-Overholt Heirarchy of Evidence Rating

Frequency

Cumulative Percentage

Level 1: Systematic review & meta-analysis of randomized control trials (RCT) or evidence-based clinical practice guidelines

1

10%

Level 4: Case control & cohort studies

3

40%

Level 6: Single descriptive or qualitative study

4

80%

Level 7: Expert opinion

2

100%

Totals

10

100%

Appendix D.

References

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Alkhalaileh, M. A., Khaled, M. H. B., Baker, O. G., & Bond, E. A. (2011). Pender's health promotion model: an integrative literature review. Middle East Journal of Nursing, 5(5), 12-22. doi:10.5742/MEJN.2011.55104

Alligood, M. R. (2013). Nursing Theoriests and Their Work. St. Louis, MO: Elsevier.

Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2013). Harm Reduction: Compassionate Care Of Persons with Addictions. MEDSURG Nursing, 22(6), 349-358.

Bradbury-Golas, K. (2013). Health Promotion and Prevention Strategies. Nursing Clinics of North America, 48(3), 469-483. doi:http://dx.doi.org/10.1016/j.cnur.2013.04.003

Draanen, J. v., Corneau, S., Henderson, T., Quastel, A., Griller, R., & Stergiopoulos, V. (2013). Reducing Service and Substance Use Among Frequent Service Users: A Brief Report From the Toronto Community Addictions Team. Substance Use & Misuse, 48(7), 532-538. doi:10.3109/10826084.2013.787096

Eversman, M. (2012). Harm reduction practices in outpatient drug-free substance abuse settings. Journal of Substance Use, 17(2), 150-162.

Ford, R. (2010). An analysis of nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Australian Journal Of Advanced Nursing, 28(1), 14-24.

Ford, R., Bammer, G., & Becker, N. (2008). The determinants of nurses’ therapeutic attitude to patients who use illicit drugs and implications of workforce development. Journal of Clinical Nursing, 17, 2452-2462.

Gray, M. T. (2014). Agency and Addiction in a Harm Reduction Paradigm: French Nurses' Perspectives. Archives of psychiatric nursing, 28(1), 35-42.

Harm Reduction Coalition (2016). Principles of Harm Reduction. Retrieved from http://harmreduction.org/about-us/principles-of-harm-reduction/

Henwood, B. F., Padgett, D. K., & Tiderington, E. (2014). Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. The journal of behavioral health services & research, 41(1), 10.1007/s11414-11013-19318-11412. doi:10.1007/s11414-013-9318-2

Lewis, D. A., Ju Nyeong, P., Vail, L., Sine, M., Welsh, C., & Sherman, S. G. (2016). Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition. American Journal of Public Health, 106(7), 1243-1246. doi:10.2105/AJPH.2016.303141

Lightfoot, B., Panessa, C., Hayden, S., Thumath, M., Goldstone, I., & Pauly, B. (2009). Gaining Insite: Harm reduction in nursing practice. Canadian Nurse, 105(4), 16-22.

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed., p. 13). Philadelphia, PA: Lippincott Williams and Wilkins.

Michels, I. I., & Stöver, H. (2012). Harm reduction—From a conceptual framework to practical experience: The example of Germany. Substance use & misuse, 47(8-9), 910-922.

National Institute on Drug Abuse (NIDA). (2008). Addiction science: From molecules to managed care. Retrieved from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching1.html

National Institute on Drug Abuse. (2015). Trends and Statistics. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics

Öztuna, F., Aytemur, Z. A., Elbek, O., Kılınç, O., Küçük, Ç. U., Akçay, Ş., & Dağlı, E. (2014). Can the Use of Smokeless Tobacco Products Be Accepted as a Harm Reduction Method in Tobacco Addiction? Turk Toraks Dergisi / Turkish Thoracic Journal, 15(4), 136-141. doi:10.5152/ttd.2014.3875

Parhiala, J. & Quinn, P. (2017). Examining knowledge levels and attitudes of nurses caring for patients with substance use disorders: A pilot study. Poster session presented at the Sigma Theta Tau International 28th International Nursing Research Congress, Dublin, Ireland.

Pauly, B. B., Goldstone, I., McCall, J., Gold, F., & Payne, S. (2007). The ethical, legal and social context of harm reduction. Canadian Nurse, 103(8).

Stockwell, T., Reist, D., Macdonald, S., Benoit, C., & Jansson, M. (2010). Addiction research centres and the nurturing of creativity: The Centre for Addictions Research of British Columbia, Canada. Addiction, 105(2), 207-215. doi:10.1111/j.1360-0443.2009.02789.x

Szott, K. (2015). Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine, 19(5), 507-522. doi:10.1177/1363459314556904

Torraco, R. J. (2005). Writing Integrative Literature Reviews: Guidelines and Examples. Human Resource Development Review, 4(3), 356-367. doi:10.1177/1534484305278283

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Clinicians’ perspectives and utilization regarding harm reduction in nursing practice in care of persons with addiction: A literature review

Clinicians’ perspectives and utilization regarding harm reduction in nursing practice in care of persons with addiction: A literature review

Audrey Killarney, BS

Prof. Michelle Neuman, MSN, APN, RN

NSG 598: Graduate Research Synthesis

18 August 2017

Introduction

Background & Significance

Harm reduction is a concept best described as the recognition that individuals will engage in unhealthy behaviors, and the goal is to minimize the associated potential harm. (Stockwell, Reist, Macdonald, Benoit, & Jansson, 2010). Classically, it was used an alternative model of care for treating smokers and controlling the spread of HIV and hepatitis B (Henwood, Padgett, & Tiderington, 2014). However, in the context of medicine, harm reduction allows the clinician to accept that the patient may continue a harmful behavior, and their duty as a clinician is to minimize the relative risks and harms associated with that behavior (Öztuna et al., 2014). Most recently, harm reduction has been introduced as a means to address treatment for persons with addiction (Aldridge, 2012). These patients carry complex medical and social histories, for which traditional “treatment first” approaches may not be appropriate (Henwood et al., 2014). For example, Draanen et al. (2013) found an associated mental disorder in over 1/3 of patients who abuse alcohol, and over half of patients who abuse drugs. This finding supports the hypothesis that patients with severe mental illness often self-medicate with drugs and/or alcohol to control their psychosis (Henwood et al., 2014).

Previous studies have consistently reported that patients with addiction are more likely to be immune-compromised and have poor nutritional status, which can greatly affect their response to medical treatment (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013). These individuals are also more likely to delay seeking medical treatment for acute issues, resulting in hospital visits for far more severe and advanced illnesses (Ford, Bammer, & Becker, 2008). Harm reduction allows for clinicians to assess other aspects of a patient’s well-being, such as secure housing, employment, and social support, which may contribute to recovery and/or relapse (Henwood et al., 2014).

Harm reduction holds great significance in current nursing practice given the recent rise of substance abuse and overdose deaths in the United States. In 2014, it was estimated that abuse of tobacco, alcohol and drugs cost the United States over $700 billion in loss of productivity, healthcare, and crime (National Institute on Drug Abuse, 2015). These numbers are significant, as harm reduction interventions in Canada have been able to alleviate hospital-based costs, reduce ED visits, as well as reduce overnight hospital stays (Draanen et al., 2013). A growing problem in the United States surrounds the epidemic of opioid overdose. Heroin overdoses account for the fastest growing group of overdose deaths, with a 6-fold rise over the period of 2001-2013 (National Institute on Drug Abuse, 2015). In response to rising heroin overdose rates, overdose education and naloxone distribution (OEND) programs are increasing nationwide. These types of programs are commonly sponsored by the Harm Reduction Coalition, as they seek to reduce potential risks and mortality associated with drug use. This finding further supports the argument for inclusion of harm reduction in the care of persons with addiction (Lewis et al., 2016).

Nurses in particular, are positioned to experience situations in which harm reduction strategies may be appropriate. Nursing staff are frequently involved in patient education, and re-education, of hospitalized patients; while an individual may not be ready to receive treatment, nursing staff could be qualified to provide information regarding self-help groups (Bartlett et al., 2013). Additionally, nurses conduct many of the initial screenings during hospitalization; these screenings include alcohol and drug abuse questionnaires that provide a bridge to discussions regarding use and healthy use of alcohol, prescription drugs and illicit substances (Bartlett et al., 2013). Furthermore, nursing practice acts in a few states including North Carolina, New York, and California, allow for nurses to conduct counseling on reducing the adverse effects of a patient’s addiction. However, little information is readily available about the implications of nursing staff utilizing harm reduction in the United States (Bartlett et al., 2013).

Purpose

The purpose of this integrative literature review was to identify how nursing practice can utilize harm reduction in the care of persons with addiction. This review examined the use of harm reduction for addiction patients and its efficacy. Additionally, the review focused on studies in which clinicians offer their perspectives and attitudes towards harm reduction.

Research Questions

  1. What are clinicians’ perspectives regarding use of harm reduction strategies in the care of persons with addiction?
  2. Which practices are employed to ensure successful harm reduction utilization in care of persons with addiction?

Conceptual Model/Theoretical Approach

The conceptual model most appropriate for this study was Pender’s Health Promotion Model (HPM). Originally developed in 1982, Pender’s theory views the patient as a holistic being requiring a multidisciplinary approach to health (Alkhalaileh, Khaled, Baker, & Bond, 2011). A revised version of model map is attached in Appendix A. Key assumptions of the HPM include that individuals have the ability for self-awareness, they have the desire to regulate their own behavior, and that health professionals are a part of the interpersonal environment which carries the potential to influence patient behavior towards their health (Alligood, 2013). Pender identified 14 theoretical assertions to describe the HPM; of those, 3 assertions were identified as correlating with harm reduction:

“3. Perceived barriers can constrain the commitment to action, the mediator of behavior, and the actual behavior…

7. When positive emotions or affect is associated with a behavior, the probability of commitment and action is increased…

13. Commitment to a plan of action is less likely to result in the desired behavior when competing demands over which persons have little control require immediate attention,” (Alligood, 2013, p. 403).

Pender’s model aligns well with the harm reduction approach as one of the key tenants of harm reduction, is the recognition that individuals possess autonomy over decisions related to their health care (Szott, 2015). Additionally, harm reduction addresses the holistic factors that contribute to the ultimate goals of sobriety: education, employment, housing, co-morbidities, and stress management. Harm reduction also places emphasis on gradually creating new behaviors as a means to prevent relapse (Bradbury-Golas, 2013).

Methods

Design

This study employed an integrative literature review to assess how, if at all, harm reduction has been integrated into nursing practice. Integrative literature reviews can be especially helpful to analyze new or emerging topics in a given field (Torraco, 2005). An integrative literature review allows for a holistic approach to gathering information regarding the topic given that the topic of harm reduction in nursing is relatively underdeveloped. Additionally, integrative literature reviews can synthesize the various literature, in order to produce a clearer picture of the phenomenon or research question (Torraco, 2005).

Literature Search Strategies

In order to acquire literature for this integrative literature review, the following databases were used: CINAHL complete, PubMed, and ProQuest Nursing and Allied Health Source. The following search terms used were as follows: “harm reduction & nurs*,” and “harm reduction & addiction,”.

Inclusion & Exclusion Criteria

Articles were selected if they were in English, published within the last 10 years (2006-2016), published in an academic peer-reviewed journal, and were primary sources. Literature was analyzed if the focus included the following topics: current harm reduction strategies, clinician perception of harm reduction, nursing care of persons with addiction, treatment centers that employ a harm reduction approach, and nursing position pieces on harm reduction. Of the 99 articles retrieved, 10 were analyzed in the integrative literature review. The remaining 89 articles were excluded due to the following parameters: duplicate article, application of harm reduction to alternative health disparities (fall prevention, smoking cessation, or cardiovascular disease), no clear relationship to nursing practice, or a position piece. The articles chosen for review are outlined in more detail in the included research matrix (Appendix B).

Results

Results of the integrative literature review yielded 4 articles regarding clinicians’ perspectives on harm reduction use, and 6 articles regarding current use of harm reduction in nursing practice. Selected literature was rated using the Melnyk Fineout-Overholt Hierarchy of Evidence (2011) (Appendix C). Analysis of the literature regarding clinicians perspectives on harm reduction use revealed common themes such as: consistency with nursing ethics; harm reduction as honoring a patient’s autonomy; and socio-cultural challenges related to harm reduction use. Literature regarding current use of harm reduction revealed themes such as: harm reduction’s ability to address the patient as a holistic being; nursing’s role as patient advocate; and harm reduction as a bridge to abstinence.

Clinician’s Perspectives on Harm Reduction Use

Nursing Ethics. A region’s specific nursing code of ethics can often be interpreted as aligning with the tenants of harm reduction. The Canadian Code of Ethics for Nurses states "that nurses have a responsibility to provide 'persons in their care with the information they need to make informed decisions related to their health and well-being.' " (Lightfoot, 2009, p.21). This responsibility and duty does not preclude drug abuse and misuse. The Canadian Nurses’ Association has published a position piece as a means to gain greater acceptance of harm reduction in the workplace. They describe, in detail a well-known harm reduction facility known as “Insite” which provides counseling, needle-exchange "The practice of its nurses is guided by core principles of harm reduction and health promotion that are central to achieving Insite's objectives and consistent with professional ethical standards." (Lightfoot, 2009, p.21)

Patient Autonomy. An important tenant of both harm reduction and nursing ethics is patient autonomy. Many studies cited historical roots of paternalism in treating patients with addiction; however, harm reduction reflects “…a client-centered philosophy and a recovery orientation where clients are driving goal setting and where care plans are based on clients’ strengths and choices,” (Drannen, 2013, p.534). This is impactful in that clients are able to take ownership of their recovery, increasing the likelihood that they will succeed. Additionally, many studies citing usage of harm reduction cautioned clinicians towards directing a patient to recovery as it may foster feelings of resentment and resistance. The shifting of responsibility of recovery from clinician to patient also alleviated a great deal of stress from the clinician in that it was not their personal goal that needed to be achieved.

Socio-cultural challenges. While there were many studies in support of harm reduction, it was not met without criticism or skepticism by clinicians working in drug-free treatment centers. Clinicians cited that a harm reduction approach would be in direct contradiction to their program and recovery model. Many clinicians also expressed fear of legal action or loss of license. Clinicians working in methadone maintenance facilities and safe needle exchange facilities in the U.S., cited greater issues with accessing affordable and subsidized housing for clients, that was not contingent upon abstinence. Studies coming from European countries cited harm reduction’s alliance with the EU’s policy that individuals with addiction have the right and ability to take ownership of their recovery (Gray, 2014, p.39). Even with support from governmental authorities and nursing bodies, most studies continued to acknowledge the disparities and prejudice addicts face in society; this prejudice can be alienating to an addict and prolong the time to seek treatment.

Current Use of Harm Reduction in Nursing Practice

Holistic care. Several harm reduction programs and interventions exist in Canada to address their specific substance abuse problems. Toronto is unique in that it has created a case management program designed to intercept individuals before reaching the emergency department, and connect them to social services of which they’re eligible. The Toronto Community Addictions Team (TCAT) is a program that “…aims to create a model of care that includes the promotion of empowerment, respect, and dignity, ensuring services are delivered in the least restrictive, intrusive, and stigmatizing ways,” (Drannen, 2013, p.534). An important component of harm reduction is its ability to connect clients with social services. Persons suffering from addiction often experience a variety of social challenges ranging from housing insecurity, mental illness and lack of financial management; programs like TCAT seek to address the person as a holistic being, and seek to correct factors that may contribute to relapse. Additionally, clients develop trusting relationships with clinicians in harm reduction facilities, thus engaging and retaining them in social services.

Advocacy. Advocacy, and the nurse as advocate, were described in a variety of settings. The Canadian Nurses’ association urges all nurses to educate themselves in harm reduction practices; they state, "all nurses should be well informed about harm reduction interventions and their place in the preventions, care and treatment continuum, so that they can humanely care for those who use drugs by referring to and advocating for all types of evidenced-based addiction supports," (Lightfoot, 2009, p.21). In settings utilizing harm reduction, clients expressed favorable feelings towards having someone whom they felt could speak on their behalf, and had their best interests in mind. This is especially important for patients who harbored distrust towards healthcare professionals. Clients also expressed gratitude at having someone with whom they trusted able to manage their finances. Having a safe and secure place in which to keep their money reduced fear that they may be robbed. Clients were also grateful to be able to see progress towards financial security; this was evident in greater money saved on a weekly basis, and less money spent on drugs and alcohol. Advocacy can also be interpreted from the perspective of nursing policies and drug enforcement laws. Nurses hold positions of influence in both their local, state, and federal governments; they serve as liaisons to legislators who may not be familiar with the current state of healthcare. In regions unfavorable to addicts, “action on drug policy reform must be part of a broader agenda to enhance social justice that seeks to take action on the underlying conditions that produce poor health such as homelessness, violence, poverty, and racism," (Pauly, 2007, p.22).

Bridge to abstinence. One of harm reduction’s key tenants relies on the understanding and assumption, that a patient may continue to use or abuse substances during their treatment. Several studies have suggested harm reduction’s ability to serve as a bridge to abstinence, rather than an alternative to abstinence. An ethnography qualitative research study of addiction nurses in France offers this perspective of their work: “I always insist on not making things go smoothly for the patients. The treatment framework is in place to be transgressed…. Transgression is the essence of therapy,” (Gray, 2014, p.37). While this idea may seem counterintuitive to the traditional medical model, in which clinicians facilitate recovery, it reflects a realist mentality common in harm reduction practices. Additionally, it removes the shame and guilt often associated with relapse. Clinicians described relief when clients were open and honest about their relapses; this honesty allowed them to continue a relationship based on trust and mutual respect. Studies regarding current use of harm reduction regularly state that abstinence is not a requirement for treatment, and clients take responsibility for directing the pace of recovery. Goals of German harm reduction programs are, “to stabilize the drug addict's health status and gradually move them toward abstinence." (Michels, 2012, p.917)

Discussion

Clinician perspectives of harm reduction revealed a view of harm reduction as honoring a patient as a holistic being, and ability to serve as a better advocate. While still acting as an advocate, clinicians felt they were better able to honor a patient’s autonomy in decision-making. Patient autonomy, and trust in a patient’s ability to make health related decisions, is one of the key tenants of Pender’s Health Promotion Model; both perceived self-efficacy and perceived barriers to action greatly influence a patient’s commitment to action, and ultimately the adoption of a health promoting behavior. Studies regarding current use of harm reduction found positive results in patients’ self-reported advocacy, self-esteem, and ability to navigate social services. Patients also experienced a decrease in problems associated with drug and alcohol use, as well as a decrease in money spent on drugs or alcohol.

In addition to the evidence-based successes, the ethical components of harm reduction align with much of the nursing code of ethics. When looking towards gaining “buy-in” from American nursing executives, this will be especially useful. The nursing code of ethics largely guides individual states’ nurse practice acts. While several states have allowed for special considerations for nurses desiring to practice harm reduction, there is much work to be done to gain approval across the rest of the country. On the individual level, there are best practices that a nurse can employ to incorporate harm reduction into their everyday practice regardless of the setting in which they work. They exist on a hierarchy from the immediate level (treating drug users with dignity and autonomy) to a government level (advocating for policy changes to decriminalize users). The model is further described in a theoretical model (Appendix D).

Limitations

Limitations of this integrative literature review included the limited studies in the United States, few quantitative studies, and few studies from well-known and reviewed journals. Limitations of this studied also included few studies directly related to nursing. Many of the studies came from drug treatment facilities with nurses, as well as physicians and social workers on staff.

Direction for Future Research

Future steps for this research would include surveying nurses of a variety of hospitals in an urban setting regarding their knowledge and feelings towards harm reduction. The information garnered from these surveys would allow researchers to objectively quantify and qualify the level of nursing knowledge, to formulate impactful and appropriate nursing education in their institution. A recent pilot study from Massachusetts General Hospital identified a deficit in professional nurses’ confidence and preparedness in caring for persons with substance use disorders (SUD); results of the pilot study found nursing attitudes towards persons with SUD’s to be more positive following a 6-month training program for the CARN (Certified Additions Registered Nurse) exam (Parhiala, J. & Quinn, P., 2017). A similar single site study could be performed to first assess attitudes and confidence in nurses regarding caring for persons with SUD’s, in order to formulate an appropriate intervention for clinicians.

Nursing Implications

As aforementioned, nurses are perfectly poised to both identify patients in need of harm reduction strategies, as well as incorporate basic harm reduction techniques into their care. Nurses are also at the front-line of patient-centered care, and serve as examples to other healthcare staff on patient-centeredness. Additionally, nurses must be aware of the attitudes and beliefs of fellow clinicians towards persons with addiction

Conclusions

This integrative literature review provided a great deal of information regarding clinician perspectives of harm reduction and a few isolated studies of current use of harm reduction in clinical practice. Given the rapidly increasing rates of drug abuse and overdose, it would behoove facilities to train all registered nurses, regardless of their specialty, in basic knowledge of addiction and treatment options.

Appendix A.

Appendix B.

Citation

Phenomenon

& Research Question

Design, Methodology

& Analysis

Population

Results/

Findings

Critique/

Evaluation

Thematic Category

Draanen, J. v., Corneau, S., Henderson, T., Quastel, A., Griller, R., & Stergiopoulos, V. (2013). Reducing Service and Substance Use Among Frequent Service Users: A Brief Report From the Toronto Community Addictions Team. Substance Use & Misuse, 48(7), 532-538.

Examine the efficacy of an intensive case management team (TCAT) serving substance abusers with high healthcare utilization.

Both qualitative and quantitative methods were employed. Semi-structured interviews were performed with 10 male clients, 9 months after enrollment in the program. Interviews were transcribed and analyzed using “thematic analysis”. Measurable changes were identified using quantitative methods with validated tools such as the Multnomah Community Ability Scale (MCAS) & the Addiction Severity Index (ASI). Results were analyzed using a paired t-test and SPSS software.

Adult, substance abusers in the Toronto area, enrolled in the TCAT (Toronto Community Addictions Team).

Qualitative: Participants identified themes of advocacy, trusteeship, navigation, access and support; almost every participant spoke of the importance of having someone to talk to.

Quantitative: 43% of participants identified a corresponding mental illness, 90% were unemployed, and 55% had a history of family substance abuse. Clients decreased their withdrawal management services use significantly after 12 months of follow-up.

Dedicated case management teams, along with social support and non-judgmental treatment attitudes contribute to better continuity of care and outcomes for patients.

Case management

Harm Reduction Efficacy

Service Usage

Eversman, M. (2012). Harm reduction practices in outpatient drug-free substance abuse settings. Journal of Substance Use, 17(2), 150-162.

Drug-free/non-drug substitution treatment practices have been cited as hindering utilization and retention of substance abusers. While harm reduction is an alternative approach, little is known about providers’ views.

Qualitive study, conducted using semi-structured interviews of healthcare providers in substance abuse settings. Interviews were audio recorded, transcribed, and analyzed using Atlas TI software for meaningful quotations and themes.

Front-line practitioners in outpatient drug-free facilities within a 50-mile radius of a “medium-sized Northwestern US city”.

Support for practices such as tapering plans, non-abstinence treatment goals and substance use management was limited. However, respondents reported generally being in favor of the idea of “harm reduction philosophy”.

While there is support for harm reduction, the study did a generally good job of identifying agency practices & policies that are likely to conflict with harm reduction.

Clinician perspectives

Agency policy

Conflicting treatment ideologies

Harm reduction as a guiding principle.

Gray, M. T. (2014). Agency and Addiction in a Harm Reduction Paradigm: French Nurses' Perspectives. Archives of psychiatric nursing, 28(1), 35-42.

Psychiatric nurses possess a unique perspective on the treatment of individuals with addiction. Their challenges, beliefs, and practices are largely unknown in the EU.

Ethnography, a type of qualitative research, was employed. The researcher lived in the south of France for 5 months as part of an immersion experience. Two psych hospital directors were contacted, and they were able to provide nurses for interviews. Semi-structured interviews were performed, translated into English, coded and analyzed for themes and key words/phrases.

French psychiatric nurses in the south of France.

Nurses identified themes: agency (individuals’ autonomy), boundary setting, effective therapy.

Nurses raised important concerns about maintaining a patients’ ability to choose. Additionally, they provided insight on navigating the complicated nurse-patient relationship. Reiterated idea that addiction is a global phenomenon.

Efficacy

Ethics: Autonomy

Henwood, B. F., Padgett, D. K., & Tiderington, E. (2014). Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. The journal of behavioral health services & research, 41(1), 80-89.

Housing services for displaced individuals are typically drug-free, or post-substance abuse treatment. Analyzes provider views of harm reduction practices/abstinence in working with patients who have experienced homelessness.

Multiple in-depth interviews with 41 providers dually enrolled in the “New York Services Study”, a longitudinal study. 20 providers were members of the “housing first” group, and 21 providers in the “treatment first” group. Thematic analysis employed with ATLAS.ti software.

41 front-line providers working in homeless services in New York, whose patients were enrolled in the NYSS.

Identified themes such as a “welcomed alternative”, working with ambiguity, accommodating abstinence.

Strong study in that it included providers from both settings. Brings to light many of co-existing social issues compounded by substance abuse. Maintains a stance that the housing first model can integrate abstinence. Harm reduction exists on a continuum of practices.

Application of Harm reduction

Clinician views

Social implications

Lewis, D. A., Ju Nyeong, P., Vail, L., Sine, M., Welsh, C., & Sherman, S. G. (2016). Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition. American Journal of Public Health, 106(7), 1243-1246.

Overdose education and naloxone distribution (OEND) programs are often targeted at opioid users. However, states are now passing laws to educate and train third-party individuals on overdose prevention & naloxone administration.

Longitudinal study consisting of pre/post training surveys & follow-up surveys conducted over the phone. Participants took part in an OEND program conducted by Baltimore Student Harm Reduction Coalition. Data analyzed using McNemar test in Stata software.

Individuals >18y/o in Maryland

Statistically significant increase in knowledge about overdose, and ability to help in the instance of an overdose. No shift in perception of criminal implication from law enforcement. 86% of participants on follow-up surveys states they had told others they were trained and had naloxone. 3 participants reported overdose reversal, & 2 cases reported a parent unsuccessfully being able to reverse overdose.

In just 8 months, a student run organization could train 285 individuals in overdose and naloxone administration, resulting in 3 successful reversals of overdose. Speaks to public’s need and desire for greater education on overdose and naloxone.

Application of harm reduction

Efficacy

Public desire

Lightfoot, B., Panacea, C., Hayden, S., Thumath, M., Goldstone, I., & Pauly, B. (2009). Gaining Insite: Harm reduction in nursing practice. Canadian Nurse, 105(4), 16-22.

Insite, a supervised injection facility in Vancouver, has been shown to increase referrals, reduce the spread of blood-borne pathogens, and prevent overdose deaths. What is not well documented is how nursing practice coexists with harm reduction.

Editorial/position piece. Outlined past/present objectives of the organization. Cited numerous studies documenting efficacy of Insite.

N/A

Insite serves the community in several ways: relationship building, primary nursing care, education and partnership with other health and social systems.

The benefits of Insite are well documented and carry a great deal of support from a variety of studies. All nurses should be familiar with the continuum of: prevention, care and treatment.

Efficacy

Application of Harm Reduction

Intersection with Nursing Practice

Michels, I. I., & Stöver, H. (2012). Harm reduction—From a conceptual framework to practical experience: The example of Germany. Substance use & misuse, 47(8-9), 910-922.

Drug abuse is on the rise globally, and even through modern approaches to control the spread of blood borne diseases, HIV infections are on the rise globally. A comprehensive approach must be undertaken. The writers use the example of Germany to undertake this goal.

Systematic literature review of history of harm reduction and approaches to substance abuse in Germany.

N/A

Germany has a history of harm reduction measures dating back to the 1970’s. They include: opiate substitution treatment, syringe/needle exchange programs, drug consumption rooms, medical assisted treatment and heroin assisted treatment.

Overall, Germany has a vast history of harm reduction techniques used. They provide a framework for other European and western nations.

Efficacy

Intersection with Nursing Practice

Application of Harm Reduction

Policy/Practice

Pauly, B. B., Goldstone, I., McCall, J., Gold, F., & Payne, S. (2007). The ethical, legal and social context of harm reduction. Canadian Nurse, 103(8).

There is a large amount of literature regarding evidence-based practice of harm reduction; however, for successful integration, there must be “buy-in” from the ethical standpoint as well.

Case study/descriptive study of healthcare policy

Canadian nursing association (CNA)

Provides examples of harm reduction at play in many of the outlined principles in the Canadian Nursing Code of Ethics. Additional support from stakeholders in nursing and medicine.

This review did a nice job of touching on the different ethical principles in the code of ethics, and relating them back to harm reduction. However, this piece of literature would be more valuable if it were able to be compared to the American Nursing Code of Ethics.

Harm reduction in nursing practice

Ethical implications

Public desire

Szott, K. (2015). Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine, 19(5), 507-522.

The concept of addiction as a disease and harm reduction are in stark contrast to the traditional approaches of medicine. While these practices may begin to become commonplace in current medicine, provider adoption depends largely on perception.

Semi structured qualitative interviews with 13 health care providers in NY. Transcripts were coded and themes related to “harm reduction” were identified. HyperRESEARCH data software was used for analysis.

13 health care providers in NYC who provide primary care or buprenorphine/methadone treatment to people who inject drugs.

Providers identified harm reduction techniques they already use, they spoke to the comparison of addiction as a disease to both aid in their treatment of patients and patients’ acceptance of their disease process.

While the themes and discussions are valuable and interesting, the sampling of providers is in an area so specific to treating injection drug users, that they may not be representative of the general population of medical providers.

Harm reduction application

Clinician view of harm reduction

Ethical implications

Appendix C.

Melnyk Fineout-Overholt Heirarchy of Evidence Rating

Frequency

Cumulative Percentage

Level 1: Systematic review & meta-analysis of randomized control trials (RCT) or evidence-based clinical practice guidelines

1

10%

Level 4: Case control & cohort studies

3

40%

Level 6: Single descriptive or qualitative study

4

80%

Level 7: Expert opinion

2

100%

Totals

10

100%

Appendix D.

References

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Alkhalaileh, M. A., Khaled, M. H. B., Baker, O. G., & Bond, E. A. (2011). Pender's health promotion model: an integrative literature review. Middle East Journal of Nursing, 5(5), 12-22. doi:10.5742/MEJN.2011.55104

Alligood, M. R. (2013). Nursing Theoriests and Their Work. St. Louis, MO: Elsevier.

Bartlett, R., Brown, L., Shattell, M., Wright, T., & Lewallen, L. (2013). Harm Reduction: Compassionate Care Of Persons with Addictions. MEDSURG Nursing, 22(6), 349-358.

Bradbury-Golas, K. (2013). Health Promotion and Prevention Strategies. Nursing Clinics of North America, 48(3), 469-483. doi:http://dx.doi.org/10.1016/j.cnur.2013.04.003

Draanen, J. v., Corneau, S., Henderson, T., Quastel, A., Griller, R., & Stergiopoulos, V. (2013). Reducing Service and Substance Use Among Frequent Service Users: A Brief Report From the Toronto Community Addictions Team. Substance Use & Misuse, 48(7), 532-538. doi:10.3109/10826084.2013.787096

Eversman, M. (2012). Harm reduction practices in outpatient drug-free substance abuse settings. Journal of Substance Use, 17(2), 150-162.

Ford, R. (2010). An analysis of nurses' views of harm reduction measures and other treatments for the problems associated with illicit drug use. Australian Journal Of Advanced Nursing, 28(1), 14-24.

Ford, R., Bammer, G., & Becker, N. (2008). The determinants of nurses’ therapeutic attitude to patients who use illicit drugs and implications of workforce development. Journal of Clinical Nursing, 17, 2452-2462.

Gray, M. T. (2014). Agency and Addiction in a Harm Reduction Paradigm: French Nurses' Perspectives. Archives of psychiatric nursing, 28(1), 35-42.

Harm Reduction Coalition (2016). Principles of Harm Reduction. Retrieved from http://harmreduction.org/about-us/principles-of-harm-reduction/

Henwood, B. F., Padgett, D. K., & Tiderington, E. (2014). Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. The journal of behavioral health services & research, 41(1), 10.1007/s11414-11013-19318-11412. doi:10.1007/s11414-013-9318-2

Lewis, D. A., Ju Nyeong, P., Vail, L., Sine, M., Welsh, C., & Sherman, S. G. (2016). Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition. American Journal of Public Health, 106(7), 1243-1246. doi:10.2105/AJPH.2016.303141

Lightfoot, B., Panessa, C., Hayden, S., Thumath, M., Goldstone, I., & Pauly, B. (2009). Gaining Insite: Harm reduction in nursing practice. Canadian Nurse, 105(4), 16-22.

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed., p. 13). Philadelphia, PA: Lippincott Williams and Wilkins.

Michels, I. I., & Stöver, H. (2012). Harm reduction—From a conceptual framework to practical experience: The example of Germany. Substance use & misuse, 47(8-9), 910-922.

National Institute on Drug Abuse (NIDA). (2008). Addiction science: From molecules to managed care. Retrieved from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching1.html

National Institute on Drug Abuse. (2015). Trends and Statistics. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics

Öztuna, F., Aytemur, Z. A., Elbek, O., Kılınç, O., Küçük, Ç. U., Akçay, Ş., & Dağlı, E. (2014). Can the Use of Smokeless Tobacco Products Be Accepted as a Harm Reduction Method in Tobacco Addiction? Turk Toraks Dergisi / Turkish Thoracic Journal, 15(4), 136-141. doi:10.5152/ttd.2014.3875

Parhiala, J. & Quinn, P. (2017). Examining knowledge levels and attitudes of nurses caring for patients with substance use disorders: A pilot study. Poster session presented at the Sigma Theta Tau International 28th International Nursing Research Congress, Dublin, Ireland.

Pauly, B. B., Goldstone, I., McCall, J., Gold, F., & Payne, S. (2007). The ethical, legal and social context of harm reduction. Canadian Nurse, 103(8).

Stockwell, T., Reist, D., Macdonald, S., Benoit, C., & Jansson, M. (2010). Addiction research centres and the nurturing of creativity: The Centre for Addictions Research of British Columbia, Canada. Addiction, 105(2), 207-215. doi:10.1111/j.1360-0443.2009.02789.x

Szott, K. (2015). Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners. Health: An Interdisciplinary Journal for the Social Study of Health, Illness & Medicine, 19(5), 507-522. doi:10.1177/1363459314556904

Torraco, R. J. (2005). Writing Integrative Literature Reviews: Guidelines and Examples. Human Resource Development Review, 4(3), 356-367. doi:10.1177/1534484305278283

 

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