Addiction Nursing Competencies

A Comprehensive Toolkit for the Addictions Nurse

Abstract

With the increased role of nurses in caring for patients with substance addiction, there was a clear need to develop the Addiction Nursing Competencies to guide and support the nursing workforce. A literature search revealed a lack of formal instruments to assess and guide nurses in caring for persons with substance use disorders. The Addiction Nursing Competencies were created using existing nursing education frameworks and addiction nurse care manager clinical guidelines.

Substance use disorder (SUD)-related morbidity and mortality costs the United States an enormous amount of money and lives. The use of alcohol and illicit substances results in costs more than $440 billion each year, including medical fees, lost employment productivity, and crime.¹ Data indicate that more than 2 000 000 US adults between the ages of 18 and 64 years have an opioid use disorder.² In 2019, there were more than 70 000 overdose deaths in the United States, 70.6% (49 860) of which involved opioids.³ Although there are safe, evidence-based, and effective medications for the treatment of opioid use disorder, lack of access to care has resulted in an estimated 1.3 million people without treatment.

In an effort to bridge the gap in treatment, Boston Medical Center (BMC), an urban academic medical center and the largest safety-net hospital in New England, implemented the Nurse Care Manager (NCM) Model for delivering office-based addiction treatment (OBAT) in 2003. The NCM Model of OBAT, dubbed the “Massachusetts Model” by the Substance Abuse and Mental Health Services Administration (SAMHSA), empowers nurses to play a central role in the assessment, support, and ongoing management of patients in addiction treatment while working collaboratively with providers licensed to prescribe medications for opioid use disorders in an integrated primary care setting.⁴ The NCM Model of OBAT removes barriers to care, enhances patient engagement, and improves treatment outcomes by increasing access to addiction treatment and lifesaving medications such as buprenorphine and naltrexone.⁵ The BMC OBAT clinic continues to enhance this model and currently treats more than 800 patients with SUD. The model's success has led to its expansion to more than 40 community health centers across Massachusetts and many healthcare organizations nationwide, including via a National Institute on Drug Abuse-funded clinical trial in 6 health systems, the PRimary Care Opioid Use Disorders Treatment Trial.⁶

The NCM Model of OBAT is an impactful program in that this model uses nurses, who practice within integrated healthcare settings, to play a lead role in caring for patients with SUD. Although SUDs are complex, chronic medical conditions, they have been historically viewed as social rather than medical problems. As a result, addiction treatment has traditionally occurred in settings outside mainstream healthcare. This separation has created barriers to addiction treatment that have been “costly, often harmful, and for some individuals fatal.”⁷ Patients with SUDs who engage with healthcare often do not present as primarily seeking medical attention for their use disorder. An international study showed that the presence of an SUD often doubles a person's risk of developing another chronic medical illness, such as arthritis, heart disease, hypertension, diabetes, or asthma.⁸ Persons who inject drugs (PWID) are commonly afflicted with numerous health maladies related to their substance use, including but not limited to HIV, hepatitis C, and a range of bacterial infections such as skin and soft tissue infections (SSTIs), sepsis, and endocarditis; in fact, PWID present for medical care more often than the general population. Skin infections are the leading cause of PWID presenting to the emergency department, with inpatient hospitalization related to SSTIs stemming from opioid use doubling from 1993 to 2010.⁹ Conversely, engaging patients into SUD treatment, specifically with evidence-based medications, has been found to significantly reduce the risk of all-cause mortality and acute care needs.^10,11 This speaks to the importance of reducing or eliminating the missed opportunities by nurses at each touchpoint to address a patient's SUD.

The incorporation of prevention, treatment, and ongoing recovery support services across all healthcare systems and disciplines has been identified as key to addressing the substance use epidemic.⁷ In particular, studies highlight nursing challenges in caring for patients with SUDs, including stigma and lack of knowledge.^12-15 Despite the prevalence of SUDs, nurses have commonly expressed a lack of training in addiction care during formal education.^12,13,16 Inadequate nursing training and lack of knowledge may attribute to the gap of patients who need treatment to those receiving treatment. One study found only 37% of nursing schools provided education on counseling patients with SUDs.¹⁷ A cross-sectional study of baccalaureate nursing programs in the United States revealed limited content concerning the treatment of SUDs throughout their nursing curriculum.¹⁸ Given the prevalence of SUD among the general population, a nurse in any medical setting may be the 1st clinical provider a patient with SUD will encounter. Although nurses may ask about substance use, they rarely use formal screening tools.¹⁹ The combination of these challenges and shortcomings in formal training leaves nurses feeling underprepared to care for individuals affected by this public health crisis.

Competency frameworks are known to provide clear expectations of clinicians and organizations and are used to assess the learning needs of nurses at hiring and routine performance reviews and identify professional development goals.²⁰ The nursing competencies developed by the BMC clinical expert team were created to address the nursing knowledge gap and to empower nurses and institutions to better care for patients with SUDs. The Addiction Nursing Competencies are organized into 3 documents. The foundational document, “Foundation,” is adapted from the 3rd edition of the Massachusetts Nurse of the Future Guidelines.²¹ The “Competency Assessment” synthesizes the knowledge and skills described in the framing document, with an emphasis on education needed to train the novice addictions nurse. The “Skills Checklist” is a set of clinical checklists focused on technical skills derived from evidence-based practices used by current expert addiction nurses. As a whole, the Addiction Nursing Competencies provide a comprehensive and structured recommendation to guide care for persons with substance addiction and a pathway to the development and implementation of these nursing competencies into clinical practice.

Methods

The development of the Addiction Nursing Competencies began after requests from hospitals, community-based health centers, individual nurses, and nurse educators seeking a framework for the scope of practice and skills necessary to evaluate and train nurses for the addiction NCM role. An initial literature review revealed that there is only 1 scope of practice published for addictions nursing in America.²² However, this document does not provide clearly defined clinical competencies that nurses can use to adequately care for persons with substance addiction during the rapidly evolving substance epidemic.

The Nurse of the Future: Nursing Core Competencies²¹ was chosen as a guiding competency document to adapt to addictions nursing as it synthesized competencies obtained from other states, current practice standards, education accreditation criteria, national initiatives, and projected patient demographic and healthcare profiles. These competencies, as well as the nationally focused Massachusetts Nurse Care Manager Model of Office Based Addiction Treatment: Clinical Guidelines, became the foundation for the Addiction Nursing Competencies.²³

The component documents of the Addiction Nursing Competencies were reviewed in a 3-part process for validity, applicability, and generalizability to addiction nurses. The 1st review was completed by the architect of the nurse care manager model, a highly respected and experienced addictions nursing leader. The 2nd review was conducted in 2 parts with addiction nurses working within the NCM Model at BMC. The final review was completed by the entire BMC OBAT expert clinical team, including nurses and nurse practitioners certified in addictions nursing.

During the validation and review process, a 2nd literature review uncovered a more recent publication from Finnell et al,²⁴ which presents a set of competencies for nurses in caring for persons with SUDs, entitled “Standards of Professional Performance for Nursing: Competencies Related to the Continuum of Substance Use.” These standards of practice outlined by Finnell et al represent core competencies based upon the American Nurses Association Standards of Nursing Practice. This exemplary work outlines the scope of practice, education, certification, and standards of care for nurses providing care to persons with SUDs and is intended for a broad nursing audience. Our team believes this work serves as an excellent complement to the concrete skillsets and structure outlined within Addiction Nursing Competencies.

Findings

The Addiction Nursing Competencies consist of 3 documents: “Foundation,” “Assessment,” and the “Skills Checklist.” This top-down approach captures the expansive principles of nursing theory that form critical knowledge and skills.

The combined use of these tools aims to promote a standard of care in addiction nursing practice by providing groundwork for both administrative and frontline nurses to assess knowledge, support education, and build concrete skills in addiction nursing care. A section from the patient-centered care component from each document has been selected for inclusion.

“Foundation” outlines the theoretical foundation of quality addiction nursing care including essential nursing knowledge, attitudes, and behaviors. Table 1 is an example of a section focused on patient-centered care.

Table 1 - Excerpt of Foundations From the Addiction Nursing Competencies

Patient-Centered Care
Knowledge	Attitudes/Behaviors	Skills
K3	A3	S3
Describes the importance of trauma-informed care in patients with SUDs.	• Recognizes the role that trauma plays in the development of SUDs. • Recognizes the role that SUDs have in continuing to expose patients to traumatic experiences. • Values the importance of the patient-nurse relationship regardless of the patient's willingness to disclose trauma.	• Conducts assessments with the understanding that most patients with SUDs have been exposed to some form of trauma. • Obtains all specimens, including urine specimens, in a trauma-informed way to respect the dignity and privacy of all patients. • Offers all patients resources for behavioral health intervention for traumatic experiences. • Assesses for sequelae of traumatic experiences including effects of violence, sexual assault, and/or verbal/emotional abuse.
K5	A5	S5
Describes how the competing psychosocial priorities of patients in recovery may impact their ability to adhere to individualized care plans.	• Acknowledges that the patients' SUD inherently affects their behaviors and should not personalize negative feelings or impressions from the patient.	• Warmly welcomes patients who return for reengagement in care. • Modifies treatment plans to have flexibility to meet the vacillating needs of patients in active use and recovery. • Refers patients to additional services that may be open when the patient is available to engage in treatment.

The “Assessment” is the bridge document, using the theoretical framework as a foundation to structure assessment of knowledge and skills that can be used at both the management and individual nurse levels. Supportive education for each section is noted to promote evidence-based knowledge within each domain. Table 2 is an example of a section focused on patient-centered care.

Table 2 - Excerpt of “Assessment” From the Addiction Nursing Competencies

Patient-Centered Care
Knowledge	Skills	Supportive Education
∎ Understand local resources for psychiatric support ∎ Assess patients for sequelae of traumatic experiences and depressive symptoms/SI, and connect patients to a behavioral health clinician based on site protocol	□ Use screening tools for depression (eg, PHQ-2 and PHQ-9). □ Use screening tools for anxiety (eg, GAD-7). □ Apply protocol for management of patient in need of urgent psychiatric support within organization. □ Know emergency resources through local emergency departments.	□ SAMHSA Tip 48a □ Review of site-specific protocols and procedures □ National Alliance on Mental Illnessb □ National Suicide Prevention Lifelinec □ SAMHSA National Support Lined □ SAMHSA Concept of Trauma and Guidance for a Trauma-Informed Approache
Understand assessment for serious harm due to patient impairment from substance use.	□ Apply knowledge around state and institutional policies regarding involuntary commitment, including a working knowledge of outcome measures.	□ SAMHSA TIP 42f
Understand safety interventions required as a mandatory reporter if individual is at risk for harm.	□ Recognize statutes as mandatory reporters.	□ Children's Bureau for mandatory reportingg
		□ Mandatory reporting for elder abuseh □ State Child Abuse & Neglect Supporti □ Confidentiality: CFR 42 part 2j

Abbreviations: GAD-7, General Anxiety Disorder-7; PHQ-2, Patient Health Questionnaire-2; PHQ-9, Patient Health Questionnaire-9; SI, suicide ideation.

^aSAMHSA. Managing depressive symptoms in substance abuse clients during early recovery: TIP 48. https://store.samhsa.gov/system/files/sma13-4353.pdf.

^bNAMI: National Alliance on Mental Illness. Getting treatment during a crisis. https://www.nami.org/Learn-More/Treatment/Getting-Treatment-During-a-Crisis. Accessed May 7, 2020.

^cHome. https://suicidepreventionlifeline.org/. Accessed May 7, 2020.

^dSAMHSA. National support line. https://www.samhsa.gov/find-help/national-helpline.

^eSubstance Abuse and Mental Health Services Administration. SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

^fSubstance Abuse and Mental Health Services Administration. Substance Use Disorder Treatment for People With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series, No. 42. SAMHSA Publication No. PEP20-02-01-004. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020.

^gChildren's Bureau. Information for mandatory reporting. https://www.childwelfare.gov/pubPDFs/manda.pdf#page=2&view=Professionals%20required%20to%20report.

^hEldercare locator. https://eldercare.acl.gov/Public/Index.aspx. Accessed May 7, 2020.

ⁱChild Welfare Information Gateway. State child abuse and neglect reporting numbers. https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspList&rolType=custom&rs_id=5. Accessed May 7, 2020.

^jCenter for Excellence for Protected Health Information. Focus: PHI. SAMHSA 42 CFR part 2 revised rule. https://www.coephi.org/. Accessed October 26, 2020.

The “Skills Checklist” outlines steps of the nursing process for specific skills to determine the proficiency of an individual nurse. This tool can be used for nurses' self-assessment and by administrators to determine nurse proficiency in each skill. Table 3 is an excerpt of a section focused on addressing recurrence of use.

Table 3 - Excerpt of “Skills Checklist” From the Addiction Nursing Competencies

Addressing Recurrence of Use	Yes	No
Discovery of recurrent use: If the patient discloses use  • Thank the patient for disclosure of recurrence.  • Provide education as appropriate.  • Make adjustments to treatment plan. If the patient does not disclose use  • Provide education as appropriate.  • Review objective data with the patient.
Collaborate with treatment team to assure the patient that recurrence of use does not result in discharge from treatment.
Assess adherence to current medications for addiction treatment.
Assess the patient's current state of intoxication/withdrawal.
Assess the current substance use of the patient including substance, amount, frequency, route, and duration of use.
Discuss the events surrounding the recurrent use: antecedents, behaviors and consequences.
Educate the patient that a UTS is an opportunity to have a frank discussion with their treatment team about their use and that it is not punitive.
Educate the patient regarding the options to revise/augment the current treatment plan.
Educate the patient regarding the overdose prevention properties of continuing their MOUD.
Educate the patient regarding Overdose Prevention and Safer Consumption Practices (as appropriate).
Determine if a dose adjustment may be indicated

Discussion

A lack of universal addiction training in the medical and nursing fields, paired with stigma, has been consistently cited as a barrier to accessing evidence-based care for people with SUDs.^12,16,25 Despite a lack of education specific to the treatment of addiction, nurses, whose scope of practice includes extensive training in chronic disease management and patient education, are ideally equipped to deliver care to complex patient populations, including persons with SUDs across the spectrum of disease severity and remission. In practice, addiction nurse care managers collaborate with providers licensed to prescribe medications for opioid use disorders to safely treat a greater number of patients, increasing overall access to lifesaving and life-restoring treatment.⁵ Existing nurse care manager models of treatment have shown remarkably high rates of successful patient outcomes, including retention in treatment, reduced rates of illicit substance use, decreased acute medical needs, and decreased mortality.^4,19 Recovery is possible for patients with SUDs, and nurses can and do make positive differences in the lives of persons with substance addiction.

Although addiction-specialized nurses are and will continue to be an essential part of the nursing workforce, all nurses need to have the foundational knowledge and clinical skills to care for persons with SUDs.²⁴ Competency frameworks provide clear expectations of clinicians and organizations and are used to train nurses and assess their ability to provide patient care.²⁰ Higher-level competencies do exist for addiction nursing, but a toolkit that outlines the complex framework and concrete clinical skills necessary to educate, train, and evaluate the nurses in this field has been lacking. The Addiction Nursing Competencies were created to expand upon existing work and further translate nursing standards of care and evidence-informed treatment guidelines into a set of documents providing the educational tools and skills necessary to effectively care for persons with SUDs. They contain layers of guidance, providing an overarching view of the patient-centered approach to care coupled with tools for detailed assessment and step-by-step skills checklists. Together, these documents guide nurses at 2 levels, for both self-assessment and managerial assessment of a nursing team.

Nursing is one of the few professions that comes entrenched with a framework to simultaneously address a person's mind, body, and spirit. The Addiction Nursing Competencies support a holistic approach to patient care, focusing on an individual's strengths, motivation, and personal definition of recovery. Paired with tools such as medications for addiction treatment and harm reduction strategies, these competencies will enable nurses to safely and effectively deliver care to persons across the spectrum of the substance addiction from active use to sustained recovery.

Limitations

Although contributors to the development of these competencies represented a wide range of expertise in treating addiction—including inpatient, outpatient, emergency department, medically supervised withdrawal, advanced practice providers, and RN roles—the geographic representation was limited to eastern Massachusetts. In addition, only 15 subject matter experts participated in the development and review of the competencies. The authors recognize that the competency framework is a living document that will need to be updated to reflect the evolving field and arising best-practice data. The authors intend to review the literature annually, and more frequently as needed, to review and revise the competencies to maintain their accuracy and relevance.

Summary

Substance use disorders are far too often life-threatening or fatal despite identified safe and effective treatment options. Just an estimated 12% of the more than 20 million Americans needing treatment for SUDs have received any form of evidence-based treatment.² Addiction-trained nurses working within existing SUD treatment models, such as the NCM Model of OBAT, have helped to reduce barriers to access of lifesaving evidence-based treatment by supporting physicians and advanced practice providers to care for a greater number of patients with medications for addiction treatment while also increasing rates of retention and reducing illicit substance use among persons engaged in care.^4,5,26 Addiction nurses within the NCM Model of OBAT, or “Massachusetts Model,” serve as an exemplar, for the model allows nurses to practice to the full scope of their license, collaborate with the multidisciplinary team addressing social determinants, and participate in the development, implementation, and dissemination of practice guidelines system-wide.^5,23 A trained and competent nursing workforce can change patient outcomes, allowing access treatment without judgment and with dignity and respect.

Healthcare consumers anticipate and deserve proficiency from the nurses caring for them. The entirety of the nursing workforce is needed to address the continuum of SUD, prevent the progression of disease, and address the harms associated with substance use.²⁴ The Addiction Nursing Competencies are intended to inform and guide nursing practice in the provision of comprehensive, evidence-based care to persons with SUDs. These competencies are not all encompassing and therefore should be reviewed and revised as the evidence base expands. An ever-evolving substance use epidemic, in addition to dynamic healthcare and nursing practice environments, requires that nursing standards be reviewed and revised as necessary, to meet the needs of the population, at a minimum of every 5 years, or more frequently if warranted.²⁷

The Addiction Nursing Competencies will be accessible through the www.bmcobat.org website for wide dissemination. With the Addiction Nursing Competencies, developed by and for nurses, nurses and nurse leaders now have a toolkit to inform practice and to develop a specialty skillset. The authors of the competencies encourage nurses to engage in this rewarding field of patient care and to publish about their experiences, furthering support and interest in the discipline.