Whether in the cardiac, general medicine, or surgical care units, the daily reality for inpatient nurses means caring for patients with co-occurring substance use disorder (SUD). By one report, 15% of hospitalized patients in Massachusetts are actively engaged in opioid, alcohol, or other substance use. For patients hospitalized for other primary complaints, SUD often complicates treatment plans or leads patients to request early discharge from the hospital against medical advice, only to quickly return to the ER or be readmitted.
Despite the considerable number of patients struggling with addiction, nurses on the front lines who often work most closely with patients receive little to no formal training on how to care for and engage with people with SUD. And exposure to only the most acute cases on the inpatient floors can also reinforce socialized stigmas, research suggests.
This dilemma has led Nancy Gaden, DNP, RN, chief nursing officer at Boston Medical Center and Miriam Komaromy, MD, medical director of the Grayken Center for Addiction, to create the Grayken Addiction Nursing Fellowship. The first of its kind in the United States, the six-month fellowship will provide RN fellows with specialized training in SUD and co-occurring disorders, with an emphasis on developing greater skills and knowledge around communication, SUD screening, addiction medications, and the network of providers and programs available to aid recovery.
The rotations will emphasize nursing-led outreach and treatment approaches and the opportunity to observe the continuum of addiction care and recovery. The pilot program is meant to empower nurses and improve hospitalized patients' care experience, explains Jason Fox, NP, a CARN-certified nurse practitioner of BMC's Addiction Consult Service and director of the fellowship.
Addiction and the role of the nurse
"We are really focusing on the role of the nurse and showing fellows the breadth and depth of treatment services and options for patients," says Fox. "Nurses are the ones caring for that patient in 12-hour shifts. If they're able to identify early a patient who's uncomfortable or in withdrawal, it can make a difference in terms of patient care."
Through clinical, experiential, and didactic learning opportunities, the fellowship will enable two nurse fellows to participate in patient care and counseling at BMC's pediatric, maternal, and outpatient addiction treatment programs. The fellows will also have the opportunity to observe outreach in community-based settings through community partners including Boston Healthcare for the Homeless' SPOT Program and the Boston Public Health Commission's Engagement Center. The goal is improving patient care, spreading knowledge about treatment and care for patients with SUD, and — through that education — minimizing stigma across the hospital, Fox says.
Kerri Fernandes, RN, one of the program's inaugural fellows, applied to the fellowship with the hope of becoming the go-to resource for colleagues caring for patients with SUD. Working as a nurse on BMC's med-surg float pool since 2013, Fernandes estimates that half of her four-person patient assignment on any given day has drug or alcohol use disorder or is in recovery. She describes addiction as a "huge monkey on the back" of hospitalized patients, often leading to so-called noncompliance issues and frustration on the part of the care team.
"It's a huge gap for inpatient nurses — we don't know what our role is. Do we talk to the patient about this? What are the correct terms to use? What are the correct words to say?" Fernandes explains. "If nurses can learn harm reduction and how to meet patients where they are, then maybe they will feel comfortable, and maybe we can start a dialogue with them with the information they'll need when they're ready to take steps toward recovery."
The inaugural fellows are both members of BMC's Substance Use Disorders Nursing Council, a forum for clinical nurses from all patient care areas to collaborate and problem solve around issues involving addiction care and the group that has been essential in initiating the fellowship. James Evans, RN, the other fellowship recipient and a new nurse on BMC's Cardiac and Geriatric unit, joined the council to help advocate for patients with addiction. He is passionate about public health outreach, having worked with BMC's Project TRUST to provide education, testing, and supplies to help people who use drugs stay safe on the streets. It is a cause close to his heart. He has lived the other side of addiction as someone who struggled with drug use.
"These nurses don't have the benefit that I do. I see people getting better every day in my personal life. And when I was doing outreach, I saw people walk into a meeting and get years of recovery, and they never go back into the hospital," says Evans. "So there is a lot of hope that I have about it. I have the ability to say no matter how acute or desperate a person might seem, they can get better. I have seen it a million times."
As an inaugural fellow of the Grayken Addiction Nursing Fellowship, Evans is looking forward to mentorships with leading addiction experts and building the experience required to sit for the Certified Addictions Registered Nurse (CARN) exam. Having been through his own recovery, he believes nurses have the human touch patients need to change their trajectory.
"I think nurses tiptoe the line a little bit with these issues. I want people to dig in. So whatever knowledge I gain from this fellowship, I want to bring back to my unit and other nurses to say 'it's okay to make mistakes, but don’t be afraid of this population. You can really make a difference here,'" he says.