General

Guideline Title

Engaging clients who use substances.

Bibliographic Source(s)

Registered Nurses’ Association of Ontario (RNAO). Engaging clients who use substances. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2015 Mar. 115 p. [179 references]

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Recommendations

Major Recommendations

Definitions for the levels of evidence (Ia, Ib, IIa, IIb, III, IV) are provided at the end of the “Major Recommendations” field.

Practice Recommendations

Assessment

Recommendation 1.1

Screen all clients to determine whether they use substances.

(Level of Evidence = V)

Recommendation 1.2

For clients who use substances, use universal screening questions and/or an appropriate screening tool to determine the level of support required.

(Level of Evidence = V)

Recommendation 1.3

Conduct a comprehensive assessment with all clients who screen positive for substance use, as appropriate based on the nurses’ knowledge, skill, time, setting and resources.

(Level of Evidence = V)

Planning

Recommendation 2.1

Build collaborative relationships with clients through the use of motivational interviewing techniques to develop the plan of care.

(Level of Evidence = Ia)

Implementation

Recommendation 3.1

Use brief intervention to collaborate with clients identified as at risk for or experiencing a substance use disorder.

(Level of Evidence = Ia)

Recommendation 3.2

Advocate for and support access to combined pharmacological and psychosocial interventions, as appropriate, and promote the appropriate use of combined interventions to improve well-being and health outcomes.

(Level of Evidence = Ia)

Recommendation 3.3

Engage youth and adolescents at risk for or experiencing a substance use disorder using family-based therapies until recovery, as appropriate.

(Level of Evidence = Ia)

Evaluation

Recommendation 4.1

Reassess the effectiveness of the plan of care until the client’s goals are met.

(Level of Evidence = V)

Education Recommendations

Education

Recommendation 5.1

Integrate theory and clinical practice opportunities regarding care of clients at risk for or experiencing a substance use disorder into the undergraduate education of nurses and other health-care providers.

(Level of Evidence = V)

Recommendation 5.2

Health-care providers participate in continuing education to enhance their ability to assess and work with clients at risk for or experiencing a substance use disorder.

(Level of Evidence = Ib)

Recommendation 5.3

Nurses practice reflectively to enhance their awareness of their current and evolving attitudes, perceptions and biases, and values and beliefs when working with clients at risk for or experiencing a substance use disorder.

(Level of Evidence = V)

System, Organization and Policy Recommendations

System, Organization and Policy

Recommendation 6.1

Advocate for improved health outcomes by:

Increasing access to integrative and collaborative care for clients at risk for or experiencing a substance use disorder; and
Reducing health inequities by dedicating resources to preventing, treating, and supporting the recovery of individuals at risk for or experiencing a substance use disorder

(Level of Evidence = V)

Recommendation 6.2

Organizations integrate prevention, assessment, and management of substance use and substance use disorders as a strategic clinical priority across all care settings.

(Level of Evidence = V)

Recommendation 6.3

Organizations integrate components of harm reduction and the social determinants of health into comprehensive, multi-faceted approaches to addressing substance use disorders.

(Level of Evidence = V)

Recommendation 6.4

Organizations use knowledge translation processes and multi-faceted strategies to integrate best practices in the assessment and management of substance use and substance use disorders across all practice settings.

(Level of Evidence = V)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials and/or synthesis of multiple studies primarily of quantitative research

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Synthesis of multiple studies primarily of qualitative research

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities

Note : Adapted from the Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer’s handbook. 2011. Retrieved from http://www.sign.ac.uk/guidelines/fulltext/50/index.html ; and Pati D. A framework for evaluating evidence in evidence-based design. Health Environments Research & Design Journal. 2011;4(3):50-71.

Clinical Algorithm(s)

An algorithm titled “Algorithm for Engaging Clients Who Use Substances” is provided in the original guideline document.

Scope

Disease/Condition(s)

Substance use

Guideline Category

Counseling
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment

Clinical Specialty

Family Practice
Nursing
Preventive Medicine
Psychiatry
Psychology

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Nurses
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Substance Use Disorders Treatment Providers

Guideline Objective(s)

To provide evidence-based recommendations for nurses and other members of the interprofessional team across all care settings who are assessing and providing interventions to individuals who use substances and may be at risk for or experiencing a substance use disorder

Target Population

Individuals aged 11 and older who use substances and may be at risk for or are experiencing a substance use disorder

Interventions and Practices Considered

Screening questions and tools to determine substance use
Comprehensive assessment with all clients who screen positive for substance use
Building of collaborative relationships with clients
Collaboration with clients identified as at risk for or experiencing a substance use disorder
Advocating for and supporting access to combined pharmacological and psychosocial interventions
Engagement of youth and adolescents at risk for or experiencing a substance use disorder using family-based therapies
Reassessment to determine the effectiveness of the plan of care
Patient/client education
Education for health-care providers at the undergraduate level
Participation of health-care providers in continuing education
Participation of health-care providers in practicing self-reflection
Advocating for improved health outcomes through systems level changes
Integration of prevention, assessment, and management of substance use and substance use disorders as a strategic clinical priority within organizations
Integration of best practices in the assessment and management of substance use and substance use disorders across all practice settings

Major Outcomes Considered

Increased screening and intervention rates
Cost efficiency
Recovery rates
Hospitalization rates
Adherence to interventions
Quality of life

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Search Strategy

Structured Web site Search

A member of the Registered Nurses’ Association of Ontario (RNAO) guideline development team searched an established list of Web sites for guidelines.

Guidelines were selected based on the following criteria:

Self-identified as a “guideline” – in title or body of article
Published in English; national and international in scope
Developed between the years of 2005 - 2014
Strictly on the topic areas listed in search terms
Available and accessible for retrieval

See the search strategy document (see the “Availability of Companion Documents” field) for a list of Web sites searched.

Hand Search

RNAO Expert Panel members were asked to review personal libraries to identify and submit potentially relevant guidelines. Guidelines submitted for consideration by panel members were integrated into the retrieved list of guidelines if they had not been identified by the on-line guideline search and met the inclusion criteria.

Concurrent with the review of existing guidelines, a systematic review for recent literature relevant to the scope of the guideline was conducted by a health sciences librarian.

Guideline Review

The RNAO guideline development team searched an established list of Web sites for guidelines and other relevant content published between 2005 and 2014. This list was compiled based on knowledge of evidence-based practice Web sites, recommendations from the literature, and key Web sites related to substance use disorder. Detailed information about the search strategy for existing guidelines, including the list of Web sites searched and inclusion criteria, is available online at www.RNAO.ca. Guidelines were also identified by members of the RNAO expert panel.

Members of the expert panel critically appraised 14 international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II. From this review, five guidelines were selected to inform the recommendations and discussions of evidence.

Systematic Review Search Strategy

A comprehensive search strategy was developed by the RNAO guideline development team in collaboration with the RNAO research team and a health sciences librarian, based on inclusion and exclusion criteria created with the RNAO expert panel. A search for relevant articles published in English, between 2005 and 2014, was applied to the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), EMBASE, MEDLINE, PsycINFO, and Applied Social Sciences Index and Abstracts (ASSIA). In addition to this systematic search, panel members were asked to review personal libraries for key articles not found through the above search strategies.

Detailed information about the search strategy for the systematic review, including the inclusion and exclusion criteria as well as search terms, is available online at http://rnao.ca/substanceuse.

Number of Source Documents

5 guidelines and 74 studies were included. See the flow diagrams in Appendix D in the original guideline document for more information on the review process.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials and/or synthesis of multiple studies primarily of quantitative research

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Synthesis of multiple studies primarily of qualitative research

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities

Note: Adapted from the Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer's handbook. 2011. Retrieved from http://www.sign.ac.uk/guidelines/fulltext/50/index.html; and Pati D. A framework for evaluating evidence in evidence-based design. Health Environments Research & Design Journal. 2011;4(3):50-71.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Guideline Review

Systematic Review

Once articles were retrieved, the records were divided equally between two teams of research associates (RA), comprised of two RAs each (three RAs are nurses holding masters degrees; one RA is an epidemiologist holding a masters degree). Each member of the team independently assessed the eligibility of their studies according to established inclusion/exclusion criteria. The Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline program manager, who was involved in supporting the RNAO expert panel, resolved disagreements between RAs within each team.

Quality appraisal scores for 24 articles (a random sample of 10% of articles eligible for data extraction and quality appraisal) were independently assessed by each RA. Acceptable inter-rater agreement (kappa statistic, κ=0.71) justified proceeding with quality appraisal and data extraction by dividing the remaining studies equally between the RAs. A final summary of literature findings was completed. The comprehensive data tables and summary were provided to all RNAO expert panel members for review and discussion.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

For this new guideline, the Registered Nurses’ Association of Ontario (RNAO) assembled a panel of experts who represent a range of sectors and practice areas. A systematic review of the evidence, which captured relevant literature published between 2005 and 2014, was based on the purpose and scope of this guideline and supported by the following three questions:

What are the most effective methods of assessment for substance use disorders for individuals aged 11 years and older?
What are the most effective interventions for individuals aged 11 years and older with a substance use disorder?
What education and policy considerations may best facilitate nurses’ care of individuals with a substance use disorder?

The RNAO expert panel’s mandate was to develop an evidence-based Best Practice Guideline that will provide nurses and other health-care providers with current best practices for engaging clients who use substances. The recommendations in this Guideline aim to bridge the identified gap between current practice and evidence-based practice.

This edition (2015) is the result of the expert panel’s work to integrate the most current and best evidence into the recommendations and provide supporting evidence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Stakeholders representing diverse perspectives were solicited for their feedback. See the “Stakeholder Acknowledgement” section in the original guideline document for additional information.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Administering standardized screening instruments in a variety of practice settings (e.g., emergency departments, primary health-care settings, acute care settings, long-term care) has been shown to reduce substance use among clients; improve access to early interventions, thereby decreasing harms to clients’ health and leading to positive client outcomes; and reduce health-care costs to the system.
The evidence suggests that even one short episode of brief intervention (BI) is efficacious in improving outcomes. BI is effective in motivating clients to change and encouraging those with more severe problems to consider referrals to specialized intervention services. It has been shown to decrease alcohol intake, risky drinking practices, and injury frequency.
Benefits of improved collaboration and coordination across the system will include a reduction in avoidable visits to emergency rooms and hospitalizations, reduced wait times for community- and hospital-based services, and improved access to community supports, helping to address the needs of clients in a more timely manner.
See Appendix K in the original guideline document for benefits of psychosocial interventions.

Potential Harms

Adverse patient reactions to treatment medication

Qualifying Statements

These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability, with respect to loss, damage, injury, or expense arising from any such errors or omissions in the contents of this work.
This nursing Best Practice Guideline (BPG) is a comprehensive document that provides resources for evidence-based nursing practice. It is not intended to be a manual or “how to” guide, but rather a tool to guide best practices and enhance decision making for nurses working with clients who use substances. The Guideline should be reviewed and applied in accordance with both the needs of the individual organizations or practice settings, and the needs and preferences of the client. In addition, the Guideline provides an overview of appropriate structures and supports for providing the best possible evidence-based care.
Nurses, other health-care providers, and administrators who lead and facilitate practice changes will find this document invaluable for developing policies, procedures, protocols, educational programs and assessments, interventions, and documentation tools. Nurses and other health-care providers in direct care will benefit from reviewing the recommendations and the evidence that supports them. It is recommended that practice settings adapt these guidelines in formats that are user-friendly for daily use.

Implementation of the Guideline

Description of Implementation Strategy

Implementation Strategies

Implementing guidelines at the point of care is multi-faceted and challenging; it takes more than awareness and distribution of guidelines to get people to change how they practice. Guidelines must be adapted for each practice setting in a systematic and participatory way, to ensure recommendations fit the local context. The Registered Nurses’ Association of Ontario’s (RNAO) Toolkit: Implementation of Best Practice Guidelines (2nd ed.) provides an evidence-informed process for doing this (see Appendix N in the original guideline document).

The Toolkit is based on emerging evidence that successful uptake of best practice in health-care is more likely when:

Leaders at all levels are committed to supporting guideline implementation
Guidelines are selected for implementation through a systematic, participatory process
Stakeholders for whom the guidelines are relevant are identified and engaged in the implementation
Environmental readiness for implementing guidelines is assessed
The guideline is tailored to the local context
Barriers and facilitators to using the guideline are assessed and addressed
Interventions to promote use of the guideline are selected
Use of the guideline is systematically monitored and sustained
Evaluation of the guideline’s impact is embedded in the process
There are adequate resources to complete all aspects of the implementation

The Toolkit uses the “Knowledge-to-Action” framework to demonstrate the process steps required for knowledge inquiry and synthesis. It also guides the adaptation of the new knowledge to the local context and implementation. This framework suggests identifying and using knowledge tools, such as guidelines, to identify gaps and to begin the process of tailoring the new knowledge to local settings.

RNAO is committed to widespread deployment and implementation of their Best Practice Guidelines (BPGs). RNAO uses a coordinated approach to dissemination, incorporating a variety of strategies including: 1) the Nursing Best Practice Champion Network®, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs; 2) nursing order sets which provide clear, concise, actionable intervention statements derived from the BPGs’ practice recommendations that can be readily embedded within electronic medical records, but may also be used in paper-based or hybrid environments; and 3) the Best Practice Spotlight Organization® (BPSO®) designation, which supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate, and sustain multiple RNAO BPGs. In addition, RNAO offers capacity-building learning institutes on specific guidelines and their implementation annually.

Information about RNAO implementation strategies can be found at:

RNAO Best Practice Champions Network: www.RNAO.ca/bpg/get-involved/champions
RNAO’s nursing order sets: http://rnao.ca/bpg/initiatives/nursing-order-sets
RNAO Best Practice Spotlight Organizations: www.RNAO.ca/bpg/bpso
RNAO capacity-building learning institutes and other professional development opportunities: www.RNAO.ca/events

Implementation Tools

Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Resources
Tool Kits

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Registered Nurses’ Association of Ontario (RNAO). Engaging clients who use substances. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2015 Mar. 115 p. [179 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2015 Mar

Guideline Developer(s)

Registered Nurses’ Association of Ontario - Professional Association

Source(s) of Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by RNAO is editorially independent from its funding source.

Guideline Committee

Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline Program Team

Composition of Group That Authored the Guideline

Development Panel Members

Sabrina Merali, RN, MN
Guideline Development Lead
Program Manager
Registered Nurses’ Association of Ontario
Toronto, Ontario

Tasha Penney, RN, MN, CPMHN(C)
Lead Nursing Research Associate
Registered Nurses’ Association of Ontario
Toronto, Ontario

Megan Bamford, RN, MScN
Nursing Research Associate
Registered Nurses’ Association of Ontario
Toronto, Ontario

Ancilla Barco, RN, MN
Nursing Research Associate
Registered Nurses’ Association of Ontario
Toronto, Ontario

Glynis Gittens, BA (Hons)
Project Coordinator
Registered Nurses’ Association of Ontario
Toronto, Ontario

Monique Lloyd, RN, PhD
Associate Director
Guideline Development, Research and Evaluation
Registered Nurses’ Association of Ontario
Toronto, Ontario

Tanvi Sharma, RN, BScN (Hons), MN (Student)
Nursing Research Associate
Registered Nurses’ Association of Ontario
Toronto, Ontario

Grace Suva, RN, MN
Program Manager
Registered Nurses’ Association of Ontario
Toronto, Ontario

Rita Wilson, RN, MN, MEd
eHealth Program Manager
Registered Nurses’ Association of Ontario
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest that might be construed as constituting an actual, potential or apparent conflict were made by all members of the Registered Nurses’ Association of Ontario (RNAO) expert panel, and members were asked to update their disclosures regularly throughout the guideline development process. Information was requested about financial, intellectual, personal and other interests and documented for future reference. No limiting conflicts were identified.

Further details are available from the RNAO.

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Guideline Availability

Electronic copies: Available in English and French from the Registered Nurses’ Association of Ontario (RNAO) Web site.

Print copies: Available from Registered Nurses’ Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Availability of Companion Documents

The following are available:

Toolkit: implementation of best practice guidelines. Second edition. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2012 Sep. 152 p. Electronic copies: Available from the Registered Nurses’ Association of Ontario (RNAO) Web site.
Registered Nurses’ Association of Ontario – Nursing Best Practice Guidelines Program: engaging clients who use substances. Guideline search strategy. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2015 Mar. 5 p. Electronic copies: Available from the RNAO Web site.
Registered Nurses’ Association of Ontario – Nursing Best Practice Guidelines Program: engaging clients who use substances. Final bibliography. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2014 Nov 18. 32 p. Electronic copies: Available from the RNAO Web site.
Sullivan L, National Native Addictions Partnership Foundation. Synopsis of First Nations substance abuse issues. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 5 p. Electronic copies: Available from the RNAO Web site.

Print copies: Available from the Registered Nurses’ Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Structure, process, and outcome indicators are available in the original guideline document.

A variety of resources, including sample prevention-based strategies, guiding questions for transtheoretical model of change, commonly used screening tools, considerations for vulnerable populations, types of psychosocial interventions, and tools for ongoing evaluation of the plan of care, are available in the appendices of the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 12, 2015. The information was verified by the guideline developer on September 16, 2015.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from Registered Nurses’ Association of Ontario (RNAO). Appropriate credit or citation must appear on all copied materials as follows:

Registered Nurses’ Association of Ontario. (2015). Engaging Clients Who Use Substances. Toronto, ON: Registered Nurses’ Association of Ontario.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.