Opioid addiction is an epidemic in every US state. A new study in the New England Journal of Medicine has linked opioid-addicted patients to the very first provider who prescribed the medication. The researchers found a correlation between the pain-prescription habits of emergency room physicians and the frequency of their patients becoming opioid-addicted. (You can read an article in the New York Times about the research here.) The bottom line? The risk of opioid addiction begins with a single exposure to narcotic pain medications—which frequently occurs during an emergency room (ER) visit.
Naturally, prescribers are in the most control: They can limit the quantity of pills prescribed after an incident, or change their prescription habits to restrict the instances warranting their use. For example, instead of patients leaving the ER with a prescription for 30 oxycodone tablets after a sprained ankle, they can prescribe 5 pills. Better still, they can prescribe ibuprofen, ice, and rest; if that becomes insufficient for pain control at home, pharmacologic methods can then be addressed.
Although physicians and advanced practice providers write the prescriptions, it is the nurses who most often provide medication education to patients at the time of discharge. It is therefore the nurse’s responsibility to ensure adequate patient education and to stress the dangers of taking opioids to their patients—even before they ever start taking the medication. Now more than ever researchers are discovering that a single exposure to these dangerous medications is enough to put opioid-naive patients at risk for addiction.
Set expectations. Patients may have a right to pain control, but they also have a right to know just how many risks opioids bring. After an injury, many patients seem to think they will be instantly pain free. It is important to manage expectations that some degree of pain after an injury or illness is normal, as their body heals and recuperates. It is when the pain become unbearable that they should turn to pharmacological relief.
Discuss alternatives. After a musculoskeletal injury, other methods of pain control can be useful. Consider teaching patients to RICE (rest, ice, compress, and elevate) their injuries, and offer other methods of pain control such as distraction, positioning, massage, heat, and ice.
Lay out the risk of addiction. Narcotic drugs are very risky medications. Teach your patients that they are dangerous and may cause addiction even in small uses. Tell your patients to take the medications very sparingly, and be firm with your language. Patients trust nurses, and their cautious attitudes can affect patient perceptions and behaviors.
Review the unpleasant side effects. Opioid pain medications have a number of serious side effects and complications. Emphasize that your patient may experience sedation, constipation, dry mouth, tolerance or dependence, confusion, nausea, dizziness, or itching as a result of using the drug. Remind them that they cannot drive while taking the medication. Teach also that they may experience withdrawal symptoms after use.
Teach the symptoms of overdose and addiction. If the patient feels like they need more of the pills to feel normal or relief, this is a sign of increasing dependence and tolerance on the drug, and they should seek medical advice. If the patient has slurred speech; feels lethargic, foggy, or confused; is difficult to arouse or has loss of consciousness; or experiences a decreased respiratory rate, small pupils, or cold clammy skin, they may be experiencing an overdose and need immediate medical attention.
Nurses may think that since they do not prescribe the medications, they have no contribution to the opioid epidemic in this country. However, as some of the most trusted professionals in health care, it is the nurse’s role to properly educate, set realistic pain management expectations, and relay the serious risks of taking these medications.
Evidence-based practice. Those three words seem to be all the buzz in health care in recent years, and there is a good reason why. Evidence-based practice (EBP) is the science of our nursing care: It keeps us current, up-to-date, and providing the best care to our patients for the best reasons.
When you break EBP down to its core, it’s an approach to making decisions and providing nursing care not just on the most current research, but also on the basis of personal clinical experience. It’s the why for your nursing care, validating your decision-making for certain tasks on the basis of outcomes and research. It incorporates the most relevant studies, literature reviews, and clinical cases, but it also emphasizes observations made in your own care over the tenure of your own practice. It aims to incorporate what you and others have found to be the most effective treatments, practices, and ideas. EBP improves patient outcomes and patient safety.
How can you bring EBP to your unit?
Use the Internet
It can be as simple as a Google Scholar search, checking Up-to-Date, or reviewing some of the recent articles from your nursing specialty’s society journal. Changes are easy to implement on the unit, whether you’re a staff nurse or a manager. Do you feel that shift report is rushed or could be improved for better patient safety? Take a look at what the literature says about the topic and what the evidence supports to increase patient satisfaction, outcomes, and safety. It’s often surprising just how much information is already published on a topic you may be interested it. Would your unit benefit from a subscription to the Annual Review of Nursing Research, the Journal of Perinatal Education, or Neonatal Network? Ask your manager to subscribe, or whether your hospital system can provide physical copies for unit reference.
Start a Unit Council
Evidence-based practice is best incorporated into nursing units with a dedicated safety nurse, educator, or EBP leader. In units without such a position, clinical practice councils can be formed by any nurse on a unit to bring together a core team of individuals to tackle unit-based issues and find literature-supported solutions. It is difficult to imagine a unit leader or manager who wouldn’t welcome this type of employee engagement in both patient safety and unit success.
It is easy to be discouraged when one considers the breadth of nursing research about a given topic. But the root of evidence-based care is in the real-world, at the bedside, and on the unit. It starts with the observation of a problem, and the drive to find the best way to fix it. You don’t have to fix the problems plaguing nursing as a profession; you are just aiming to fix issues on your own unit and in your own practice.
The PICO model can help you define a clinical question you’re attempting to address. It stands for problem, intervention, comparison, and outcome. Well-built questions identify all four components when reviewing the literature on a certain topic. It can help format your study, research, and plan of attack.
Involve New Graduate Nurses
Oftentimes, the nurses most familiar with research and clinical questions are the new graduates. New graduates today are given the tools to conduct EBP research, and have been taught the most cutting-edge and up-to-date recommendations for practice available.
Below, I talk with Lisa Shine, BSN, RN, a lab and simulations instructor at a nursing school in Virginia.
What is your background in nursing?
I got my bachelor of science in nursing from Marymount University in Virginia, and then started working in an urban DC emergency department.
How did you hear about your current position as a clinical instructor?
When I was in nursing school, I told my old lab director that I would be back someday. She told me if I had one year of nursing experience she would take me to run simulations and teach labs. After a year, I walked into her office and she gave me the job.
I teach the lab portion of a course in the fundamentals of nursing, which focuses on clinical skills and development, and I run nursing simulations for medical-surgical nursing, mother-child nursing, mental health nursing, and community health.
What is challenging about the role?
It depends. I hear ” I have kids” or “I work full time to support my family” a lot. It can be difficult to teach people who have a lot going on in their personal lives.
What is rewarding?
I love that I am able to teach our future nurses how to manage various kinds of diseases, acute and chronic. Watching the “ah-ha!” moments and recognizing the growth in my students is why I continue to do this in conjunction with a full-time night shift nursing gig in one of the craziest emergency departments in the city. It is my privilege to mentor and “raise up” the next generation of nurses. I try to build good relationships with my students. I currently have a stack of recommendations I need to write—I guess that means they like me!
Who would you recommend for this position?
I think this role would be good for anyone who wants to take a more active role in the development of the new nursing workforce, or who might eventually want to become a professor. It’s great experience. You definitely must have patience and a passion for knowledge. The baby nurses need a lot of support, so you kind of need to be nurturing and warm.
What are your future plans with your career?
Eventually, I plan to go back to school to get my master’s degree. With a master’s I will be able to teach the lecture portion of the undergraduate nursing classes. Right now, though, I enjoy teaching baby nurses clinical skills, like how to drop a good IV line and put a foley catheter in a mannequin.
As an emergency room nurse, there are several times per day when I am presented with an opportunity to provide patient education. From dispelling common myths in triage to providing discharge instructions, it is one of our most important roles as nurses to provide solid education to the patients and families we meet every day.
Whether it’s the importance of hand hygiene, or how to properly take antibiotics, or the home management of diabetes, every piece of information we can impart to a patient can make a real difference in the wellness and health maintenance of our patient population and their families. Providing patient education is just as important as the other nursing care we deliver.
In a perfect world, nurses would have unlimited time to sit with patients and make sure they’re hearing what we are saying. We would have time to assess their preferred learning methods and to help them understand. We would have time to do a 15-minute crutches demonstration, for example, or to go over every possible side effect. And some days, we can! But how can you make sure you’re not skimping on patient education when staffing is tough, you’re stretched too thin, and when patient education might otherwise fall by the wayside?
Write it out. Sometimes I don’t have the time I would like to fully explain a patient’s home care instructions, but boy am I a fast typer (thanks, electronic medical records!). It takes me only a few moments to quickly type out home care instructions. Then, anything I want them to remember I know they are at least taking home with them. This is essential, since they won’t necessarily remember exactly what I said, but can refer back later to what I wrote.
Print! Find a patient education material app or website that you like or that your facility participates with. For me, it’s Mosby or Up-to-Date, which has pages and pages of patient information and handouts designed specifically for printing and passing over to the patient. Most are written at an easy reading level and include illustrations, and many are printable in other languages, as well.
Highlight! Stick a highlighter in one of your (overflowing) scrub pockets. If you’re pressed for time, highlight the most important pieces of the discharge paperwork for easy review. There is a lot of great information in a discharge packet, but there’s also a lot of extras. Make sure to give a brief guided tour of the paperwork and point out relevant lab results, follow up instructions, and home care.
Use teach back. One of the best ways to ensure patient learning is to ask them to teach it back to you, or at least repeat it back. You would be surprised how many times you have just gone over something only to have the patient forget what you just said or have missed your point entirely! It’s worth taking a moment to say, “Now tell me, what signs and symptoms would prompt you to seek help?”
Keep it brief. Remember, most people can only remember one or two learning points. Try to pick the most important ones to emphasize with the patient, and leave the rest for the (highlighted!) paperwork.
Include family members. If an elderly person seems particularly adverse to learning about fall prevention, enlist any family members to help. Especially in the case of family caregivers, who play a crucial role in patient’s well-being at home, it’s important to involve them in the learning process.
Don’t assume that your patients already know what you’re going to say. Don’t assume that the diabetic or hypertensive patient knows to take their medications even when they’re ill. Don’t assume that parents know to give their children the appropriate dosages of medications based on the child’s weight. Don’t assume that someone with a GI bug knows to eat a BRAT diet when resuming foods and fluid intake. Say it anyway!
Allow enough time for questions. Give the patient ample time to ask any questions about follow up care, medication side effects, or any disease process or health maintenance after discharge. Make sure he or she knows who to follow up with, too. I usually phrase this as “Ask me anything right now, and direct all questions after you leave to Dr. Smith or your primary care physician.”
Don’t leave it all for discharge! Remember to provide bits of information and patient education throughout your care for a patient and not just at the end of his or her visit. This prevents overwhelming the patient with details as they are about to leave, and helps make sure more of what you say can be retained.
It is our responsibility to ensure health literacy and competency in our patients, and that can start with little bits of information and education that we can pass along all throughout our care.
Below, I interview Erin Sullivan, BSN, RN, CEN, about her experiences in critical care. She recently switched her specialty from the emergency nursing to intensive care, and shares her reflections, challenges, and some advice.
What is your background in nursing?
I graduated as a second degree nursing student from George Washington University in 2014. I was a new graduate nurse in the emergency department (ED) for about two years before I switched to the MICU (medical intensive care unit) in March 2016.
When did you decide to change specialty, and why?
I decided to switch to the ICU about 18 months into working in the ED. At the time, I was considering applying to some graduate school programs that required ICU experience as a prerequisite, so I made the switch to broaden my experience and learn a new skill set.
What do you do now and what is your job/where?
I’m working in the MICU at Northwestern Memorial Hospital in Chicago. I also still work per diem in an ED.
What was challenging about the transition to the ICU?
The biggest challenge I had in transitioning from emergency nursing to the ICU was learning how to think like an ICU nurse. There are jokes in nursing that the two types of nurses are “wired differently.” In the ED, the goal is to quickly assess, diagnose, and stabilize patients, and then to move them out to an appropriate level of care as soon as possible. In the ICU, the goals for the patient are more long term, and you have to consider a bigger picture and a larger scope than I would in the ED. It’s a completely different way of thinking, organizing, and prioritizing patient care.
What do you miss most from ER nursing?
The thing I miss most about the ED is the teamwork. I don’t know that I can quite explain the team aspect of ER nursing to someone who’s never experienced it, but there is a special camaraderie that forms between all of your coworkers. Whether it’s one of the best shifts or the worst shift ever, your fellow coworkers join together to make sure we all come out on the other side. I also miss the organized chaos that is the ED, and the anticipation of never knowing what is coming through the door next.
What do you enjoy most about the ICU?
Being in the ICU, I really enjoy being able to watch a patient progress from being critically ill to becoming well enough to leave the unit. Unlike the ED, many times you have a patient three or four shifts in a row, so you can get to know the patients in a way I never got to in the ED.
What do you want to do with your nursing career moving forward?
I’m not sure what the next step is in my career. One of the reasons I chose nursing was because there are so many different options in what you can do. For now, I’m enjoying working in the MICU and picking up in the ED every now and again to get my adrenaline fix. I’m fairly certain though that I’ll find myself back in school pursuing a graduate degree in nursing at some point.
What tips or advice do you have for someone who wants to change their specialty?
My biggest advice for anyone considering switching their specialty is just to do it. As nurses we learn new things everyday, and we shouldn’t be intimidated or scared of the challenges that come with switching specialties!
That said, do your research. Can you handle the stress of a new job right now? Are you adaptable and a quick learner? Do you get along well with new people? These are all considerations before jumping into a new specialty. For me, I was still within the broader scope of critical care. If you’re completely changing specialties, from adults to pediatrics, or from med-surg to labor and delivery, make sure you talk to people who are in that field and that it seems like the right fit for you. But remember, you can always go back!