Substance Use Disorders: A Curriculum Response

Marian L. Farrell, PhD, PMH-NP, BC, PMH-CNS, BC, CRNP

Online J Issues Nurs. 2020;25(1)

Abstract and Introduction

Abstract

In the United States, among individuals aged 12 or older, approximately 19.7 million people experienced a substance use disorder (SUD) related to use of alcohol or illicit drugs during 2017. Current curricula in nursing education lacks sufficient content and experiences to support a nursing workforce prepared to meet the needs of individuals experiencing substance use disorders. This article describes the scope of the problem, and offers one possible solution that synthesizes essential competencies developed by an expert panel blended with an integrated approach that includes a taxonomy of significant learning. We discuss the resulting framework created for change in baccalaureate nursing education about substance use disorders.

Introduction

Recent national attention has focused on exploration of interventions to reduce the opioid crisis. Misuse of opioids is part of a larger, health-related problem known as substance use disorders (SUD) or, "a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems" (American Psychiatric Association [APA], 2013, p. 483). In the United States (US), among individuals aged 12 or older, approximately 19.7 million people experienced a substance use disorder (SUD) related to the use of alcohol or illicit drugs during 2018 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). The number of individuals experiencing substance use disorders, specifically alcohol (14.5 million) and illicit drug use (7.5 million), creates an opportunity to investigate solutions, such as increasing the basic education of the workforce providing services to individuals who experience SUD (SAMHSA, 2018).

Preparation of the registered nurse workforce in the United States occurs at three different levels, culminating in a diploma, or an associate or baccalaureate degree. The result is variable educational preparation and clinical experiences. This article specifically focuses on the continued deficit of baccalaureate level nursing education programs to adequately prepare nurses to treat individuals experiencing SUD. A curriculum response to address this educational deficit is offered as part of the solution to increase competency for care received by individuals experiencing SUD.

Preparing a workforce capable of caring for these individuals is challenging. Nurses must have the requisite knowledge, skills, and competencies to provide care across the lifespan in a variety of settings (Rutkowski, 2018).

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Table 1. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN) †+
Core Nursing Content	Essential PMHN Content	Learning Outcomes Defined as Clinical Competencies	Taxonomy of Significant Learning+ Emphasis
1. Growth & Development	a. Principles of cognitive, emotional, and psychological growth with corresponding developmental milestones b. Recognition of major disorders occurring in childhood/adolescence 1. Mood disorders 2. Eating disorders 3. Conduct disorders 4. ADHD 5. Pervasive developmental disorders 6. Substance abuse/dependence c. Recognition of major disorders occurring in adulthood 1. Mood disorders 2. Psychotic disorders 3. Personality disorders 4. Substance abuse/dependence disorders 5. Anxiety disorders d. Recognition of major disorders occurring in older age 1. Depression 2. Dementia 3. Delirium	a. Demonstrate competent generalist assessment of the developmental needs of patients experiencing psychiatric disorders. b. Recognize normative versus non-normative behavioral patterns in terms of developmental milestones. c. Plan and implement and evaluate age appropriate care for patients with psychiatric disorders.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Each aspect of Fink's Taxonomy is integrated within each of the courses of the curriculum It is seamless and evolving Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
2. Neurobiological Basis of Care Practices	a. Neuroanatomical and neurophysiological basis of and relationship to observable patient behaviors and symptoms of psychiatric disorders b. Neurobiological theories of etiology of common psychiatric health disorders c. Genetics and psychiatric disorders	a. Demonstrate competent generalist assessment skills with emphasis on mental status and neurological functioning. b. Apply neurobiologic knowledge to care practices and patient teaching.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
3. Pharmaco-therapeutics and Basic Principles of Pharmacology	a. Neurobiological basis of pharmacological and somatic treatments b. Major psychotropic agents for identified psychiatric disorders that include: 1. Classification 2. Action and expected effect 3. Side effects and toxicity 4. Potential interactions with other medications and diet c. Common alternative medicine approaches used in the treatment of psychiatric disorders 1. Herbals, minerals, and vitamins 2. Other alternative treatments	a. Articulate knowledge of the neurobiological mechanism for various psychotropic medications. b. Evaluate effects of medications on patient, including symptom abatement, side effects, toxicity, and potential interactions with other medications/substances. c. Identify factors contributing to patient non-adherence. d. Teach patients to manage their own medications including strategies to increase adherence to prescribed therapeutic regimen. e. Apply pharmacotherapeutic principles to the safe administration of psychotropic medications.	Foundational Knowledge Application Integration Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs

Table 2. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued †+
4. Communication Theory and Interpersonal Relational Skills	a. Therapeutic interventions for patients, families, and groups experiencing, or at risk for, psychiatric disorders b. Therapeutic use of self with patients, families and groups experiencing, or at risk for, psychiatric disorders 1. Appropriate affective and cognitive responses to patients 2. Concept of professional boundaries with psychiatric patients and appropriate use of self-disclosure 3. Communication with patients 4. experiencing common psychiatric symptoms such as disorganized speech, hallucinations, elusions, and decreased production of speech. 5. De-escalation of aggressive 6. behavior 7. Suicide assessment techniques	a. Demonstrate therapeutic use of groups. b. Apply therapeutic communication techniques in patients, families and disorders care practices with patients experiencing common psychiatric symptoms including disorganized speech, hallucinations, delusions, and decreased production of speech. c. Demonstrate group participation/leadership skills. d. Develop professional boundaries necessary for professional care giving relationships. e. Discuss strategies for safe management of crisis situations that occur in various treatment settings incorporating principles of therapeutic communication and patient psychopathology.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
5. Clinical Decision making	a. Taxonomy systems commonly used in care of psychiatric disorders 1. NANDA 2. DSM-5 and ICD-10 3. Omaha System b. Evidence-based care principles for psychiatric disorders c. Use of outcome measurements to evaluate interventions and care strategies d. Principles of safety in various treatment settings e. Concepts of psychiatric crisis and common intervention practices with patients experiencing psychiatric crisis f. Violence 1. Anger and aggression 2. Levels and types of violence expression such as suicide, homicide, domestic violence, child and elder abuse g. Standard care practices of common psychiatric disorders including: 1. Psychotic disorders 2. Mood disorders 3. Anxiety disorders 4. Personality disorders 5. Substance abuse/dependence disorders 6. Cognitive disorders 7. Eating disorders 8. Somatoform disorders 9. Family and community violence h. Use of informatics in psychiatric nursing	a. Apply taxonomy structures to patient specific situations including the development of nursing diagnosis. b. Identify signs and symptoms characteristic of each major disorder. c. Evaluate the degree of evidence base available to support common psychiatric nursing actions. d. Implement evidenced-based care for patients with psychiatric disorders. e. Plan and implement nursing interventions appropriate to patients' needs that reflect etiological factors and standards of nursing care. f. Prioritize crisis intervention care practices with patients with psychiatric disorders. g. Assess patient potential for violence including suicide and homicide. h. Develop and implement suicide prevention strategies.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs

Table 3. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued†+
6. Patient Care Roles	a. Principles of teaching/learning theories as they relate to patients with psychiatric disorders including psychoeducational approaches b. Principles of clinical care manage with psychiatric patients c. Principles of case manager with psychiatric patients d. Principles of patient advocacy with psychiatric patients e. Consumer advocacy groups 1. NAMI 2. NMHA 3. Local resource identification f. Overlap of nursing roles with self-help models of care including 12 step models g. Principles of collaborative relationships with individuals, families, consumers and advocacy groups	a. Demonstrate ability to effectively teach patients experiencing psychiatric disorders and their families. b. Plan and evaluate for a continuum of care that provides safety, structure, and support for patients with psychiatric disorders. c. Evaluate the continuum of care for a patient experiencing a psychiatric disorder. d. Refer patients and families to advocacy organizations. e. Assist patients to access self-help groups.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
7. Health Care Settings	a. Principles of inpatient care. b. Principles of psychiatric care in emergency department settings c. Principles of community mental health d. Principles of psychiatric home care e. Relationship of acuity of care and patient needs to the setting of care f. Evolving care settings (e.g. primary care, telecare and web-based)	a. Describe available treatment options and community based resources. b. Plan and implement care in diverse settings including acute inpatient and community based settings of care. c. Analyze adequacy of care settings related to patient acuity and needs.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
8. Cultural, Ethnic, and Spiritual Concepts	a. Diversity b. Cultural, religious, and spiritual beliefs regarding mental health and illness c. Cultural issues and spiritual beliefs as they relate to psychiatric symptom expression d. Cultural/racial/ethnic diversity and impact on mental health care delivery e. Resources for culturally/linguistically sensitive PMH care	a. Demonstrate competent generalist cultural and spiritual assessment. b. Provide culturally and spiritually competent care within the scope of nursing that meets the needs of patients from diverse cultural, racial and ethnic backgrounds.	Foundational Knowledge Application Integration Human dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
9. Health Promotion and Illness Prevention	a. Concepts of mental health promotion and illness prevention b. Known risk factors of common psychiatric disorders c. Screening and referral for common psychiatric disorders d. International and national indicators on mental health (e.g. World Health Report and Surgeon General's Report on Mental Illness) e. Healthy People 2020 goals and objectives f. Standardized screening and symptom rating instruments g. IOM Reports and National Patient Safety Goals	a. Describe populations at risk for psychiatric disorders. b. Evaluate the need for screening and referral for populations at risk for psychiatric disorders. c. Assess, plan, implement and evaluate interventions related to mental health promotion and illness prevention specific to the needs of diverse communities. d. Describe standardized screening tools used to identify at risk groups. e. Plan, implement, and evaluate preventive care practices for patients at risk for, or experiencing psychiatric disorders.	Foundational Knowledge Application Integration Human Dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
10. Concepts of Chronic Illness	a. Common adaptation and coping techniques used to deal with severe and persistent psychiatric disorders b. Symptom management with those who have serious and persistent psychiatric disorders. c. Concepts of co-morbidity d. Symptom management with those who have co-occurring chronic conditions (e.g. medical conditions and psychiatric disorders and/or substance abuse and psychiatric disorders). e. Concepts of relapse, relapse prevention, recovery and resilience	a. Establish and maintain therapeutic relationships with individuals who have a severe and persistent psychiatric disorder. b. Assess common mechanisms of adaptation and coping used by patients experiencing a severe and persistent psychiatric disorder. c. Plan, implement, and evaluate a relapse prevention plan for patients experiencing a severe and persistent psychiatric disorder. d. Prioritize care strategies for patients experiencing co-morbid health states.	Foundational Knowledge Application Integration Human dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs

Table 4. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued †+
11. Ethical and Legal Principles	a. ANA Code of Ethics and patient rights legislation b. Standards of practice for PMHN c. Least restrictive treatment approaches d. Legal rights of psychiatric patients based on voluntary versus involuntary treatment status 1. Duty to protect 2. Duty to report 3. Confidentiality	a. Clarify personal values concerning working with patients experiencing psychiatric disorders. b. Advocate for patients and families with legal and ethical concerns. c. Develop plan of care to address ethical and/or legal concerns that promote individual integrity.	Foundational Knowledge Application Integration Human dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
12. Vulnerable Populations	a. Principles and concepts of working with vulnerable populations b. Access to care c. Health disparities in mental health care and outcomes 1. Developmentally disabled 2. Elders and children 3. Special needs of diverse populations 4. Marginalized populations such as homeless and jailed	a. Recognize the multiple and complex care needs of vulnerable populations. b. Plan, implement, and evaluate care strategies that protect the rights and dignity of vulnerable populations.	Foundational Knowledge Application Integration Human dimension Caring Learning How to Learn Content Mapping Areas • Growth & Development • Care of Children & Adolescents • Care of Childbearing Women • Care of the Aging Population • Care of Individuals with Neurobiological/Psychiatric Disorders/Mental Health Needs
13. Nursing Research	a. Research related to psychiatric health nursing and care delivery concepts b. Concepts of evidence based practice	a. Critically analyze research reports as a research consumer. b. Assist patients and families in interpreting and evaluating research findings. c. Utilize research findings in planning and evaluating care practices.	Foundational Knowledge Application Integration Learning How to Learn

**see definitions below
**DEFINITIONS OF COLUMN HEADINGS
1. CORE NURSING CONTENT – Evident in general baccalaureate nursing curricular content
2. ESSENTIAL MHPN CONTENT – Specific elements and core content for PMHN. For example, under pharmacology; it is assumed that the psychotropic medications are essential
3. CLINICAL COMPETENCIES OPERATIONALIZED AS LEARNING OUTCOMES – Measurable student behaviors that reflect mastery of the essential content and reflect the PMHN skills expected of a newly graduated baccalaureate prepared nurse.
†American Psychiatric Nurses Association Education Council, Undergraduate Branch. (2016). Crosswalk toolkit: Defining and using psychiatric-mental health nursing skills in undergraduate nursing education. Retrieved from https://www.apna.org/i4a/pages/index.cfm?pageid=6018
+ Fink, L.D. (2013). Creating significant learning experiences, revised and updated an integrated approach to designing college courses. San Francisco: Jossey-Bass.