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SMAD. Revista eletrônica saúde mental álcool e drogas

versão On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) v.2 n.1 Ribeirão Preto fev. 2006




Competencies for nursing care of patients with substance related disorders


Competências para a assistência de enfermagem a pacientes com transtornos relacionados ao uso de substâncias


Competencias para la atención de enfermería a pacientes con trastornos relacionados con sustancias



Madeline A. Naegle

Professor and Coordinator, Advanced Practice Psychiatric-Mental Health Nursing College of Nursing, New York University, New York, New York.





Nurses and midwives, the largest group of providers, deliver basic and specialty healthcare worldwide. They are uniquely positioned to deliver interventions for drug use, abuse and dependence. Few provide such care however, because their basic educations lacked information and clinical teaching on drug use, treatment of addictions and health. This paper identifies nursing competencies, and gives suggestions for strategies for their development. Competencies development for nurse generalists and nurse specialists should be based on current nursing and other scientific evidence from research studies, consensus statements and practice guidelines. Exemplars of evidence based interventions are described. For purposes of this paper, alcohol is identified as such; “drugs” refers to nicotine, illegal and prescription drugs.

Keywords: Nursing care, Patients, Substance-related disorders.


Enfermeiros e parteiras, que constituem o maior grupo de profissionais da saúde, prestam assistência básica e especializada ao redor do mundo. Têm potencial único com vistas a intervenções em casos de uso, abuso e dependência de drogas. Contudo, poucos entre eles prestam essa assistência porque, na sua educação básica, faltaram informações e ensino clínico sobre o uso de drogas, tratamento de dependências e saúde. Este artigo identifica competências de enfermagem e sugere estratégias para seu desenvolvimento. O desenvolvimento de competências entre profissionais gerais e especializados deve ser baseado em evidências atuais de enfermagem e outras áreas da ciência, provenientes de pesquisas, declarações de consenso e diretrizes. São descritos exemplos de intervenções baseadas em evidências. Para fins deste artigo, o álcool é identificado como tal, e “drogas” diz respeito à nicotina, drogas ilícitas e prescritas.

Palavras-chave: Assistência de enfermagem, Pacientes, Transtornos relacionados ao uso de substâncias.


Enfermeros y parteras, que constituyen el mayor grupo de profesionales de la salud, prestan atención básica y especializada en todo el mundo. Poseen potencial único con vistas a intervenciones en casos de uso, abuso y dependencia de drogas. Sin embargo, pocos entre ellos prestan ese tipo de atención porque, en su educación básica, faltaron informaciones y enseñanza clínica sobre el uso de drogas, tratamiento de dependencias y salud. Este artículo identifica competencias de enfermería y sugiere estrategias para su desarrollo. El desarrollo de competencias entre profesionales generales y especializados debe ser basado en evidencias actuales de enfermería y otras áreas científicas, productos de investigaciones, declaraciones de consenso y directivas. Son descritos ejemplos de intervenciones basadas en evidencias. Para fines de este artículo, el alcohol es identificado como tal, y “drogas” se refiere a la nicotina, drogas ilícitas y prescritas.

Palabras clave: Atención de enfermería, Pacientes, Trastornos relacionados con sustancias.




Nurses and midwives are frontline providers of basic and specialty healthcare worldwide. In many regions, they are the only individuals knowledgeable about health promotion and illness care. Because nurses and midwives are the largest group of providers, they are uniquely positioned to deliver interventions for drug use, abuse and dependence. Many are reluctant to provide such care however, because their basic educations did not include information and clinical experiences on the drug use, treatment of addictions and health implications of substance use. This paper identifies nursing competencies, and limited suggestions for strategies for there development. Competencies development should be based on current nursing and other scientific evidence from research studies, consensus statements and practice guidelines. Three evidence based interventions which are exemplars of these resources are described. Competencies are identified for nurse generalists and nurse specialists employed across settings where patients using alcohol, tobacco and other drug are treated. For purposes of this paper, alcohol is identified as such; “drugs” refers to nicotine, illegal and prescription drugs.


The need for nursing SRD competencies

The prevention, acute and long term treatment of substance related disorders are relevant to all areas of nursing practice as the majority of persons using alcohol and other drug in ways that place them at risk for health care problems never receive specialized treatment. Most physicians, nurses and social workers treat users of substance in primary care, maternity or acute care settings without recognizing the need for intervention with the use of alcohol, tobacco or other drugs. If a problem is reported or evident, practitioners often feel they have neither the time nor the skills to address it(1). Recent reviews of the literature reveal how similar alcohol and drug dependence is to other chronic diseases treated by nurses and physicians. Drug and alcohol dependencies are similarly diagnosed, show strong indicators that they are inherited, and have etiologies, pathophysiology and treatment responses like those of chronic medical illnesses. Two prominent examples are Type 2 Diabetes Mellitus, Asthma and hypertension(2).

The availability of certain drugs varies by geographic region and cultural customs generally govern the amount and types of drugs used, who uses drugs and under what circumstances drug use (including smoking and drinking) are acceptable(3). Global trends in drugs use affect millions of people. Among selected risk factors for the global burden of disease and injury, tobacco ranks fourth and alcohol fifth, with nicotine the most widely used and most addictive of drugs in industrialized and developing countries. While cigarette smoking has decreased in the last 30 years, it continues in prevalence ranging from 19.5 % [Australia] to 72.9% [Russian Federation](4); use in many countries hovers around 30% of the population. Tobacco use, highest in Chile and Argentina (45% men and 35% of women) causes approximately 1/3 of deaths from heart disease and cancer in the Latin American region(4). By 2020, it is anticipated that 1.6 billion people in the world will be using tobacco(4). Smoking cessation treatment when delivered by health care providers, significantly increases abstinence rates(5), yet many providers do not utilized recently developed evidence- based interventions for smoking cessation.

Alcohol use is worldwide and while it is declining in most developed countries, it is rising in many developing countries. Per capita consumption is highest in Slovenia [15.15 liters/adult: 15+ yrs] and lowest in Indonesia [0.13 liters](6) and patterns of heavy drinking exist in most countries(4). In the 30 countries of the Americas, habitual drinkers are a relatively small proportion of the population (10%), but they drink half of the alcohol consumed. Estimates of alcohol consumption are further deemed inaccurate because clandestine production and/or production for home use often doubles or triples that recorded. In Brazil, for example, clandestine production triples the country’s estimated per capita consumption(7). As with tobacco, men are the largest consumers of alcohol and drugs worldwide. They develop alcohol use disorders in a ratio of 5:1 men to women, a ratio that varies by culture. Cannabis is the most commonly used illicit drug worldwide, with highest use in developed countries. In the regions of the Americas, lifetime marijuana use ranges from 2% in Paraguay, to 17% in Chile to a high of 35% in the United States(7). Cocaine is the 2nd most commonly used drug in the Southern Cone and its use is linked with HIV-AIDS. An estimated 5 million people in 121 countries who are injectors of illicit many also have HIV, and in Latin America 1.3 million people are infected with HIV and the number is growing(7). Drug use is also linked with failure to finish school many countries. For example, failure to complete school is evidenced in Chile, where 20%of students use illegal drugs, and in Peru (21%)(7). Additional trends are amphetamine-type stimulant use, which is growing. The breadth of the health and social problems linked to alcohol, tobacco and drug use suggest that all practicing nurses need to know something about the health effects and the treatment of drug and alcohol abuse, misuse and dependence.


Substance related disorders competencies and their development

The attitudes, knowledge and skills which are the foundation for the development of competencies by nurses in generalist and specialist roles correspond to those recommended for other health professional groups as well(1). Recent progress in documenting the prevalence of alcohol and other drug related disorders provides new directions for education and practice by all health disciplines. From the policy perspective, WHO, as well, has published Guiding Principles on Drug Demand Reduction aimed at preventing the use of drugs and reducing the adverse consequences of drug abuse. WHO has called for United Nations members to adopt measures to eliminate and/or reduce illicit demand for narcotic and psychotropic substances. WHO Strategies to Reduce Illness and Disability provide a baseline for interventions in all world regions and are reference points for nursing and midwifery education, legislative action, research and practice. These strategies emphasize:

  1. early diagnosis,
  2. medical/social problems,
  3. counseling and access to services and opportunities to achieve social integration
  4. medical detoxification and long term identification and management of risk of infectious disease and other care to decrease risk of relapse(8).

In order to effectively deliver care, nurses need not only knowledge, but the skill in practice. This combination is evidenced in competencies. Competency based education is an integrated program of competency based outcomes, interactive learning methods and performance assessment tools which focus on the abilities for practice of a discipline(9). Competencies describe behaviors measured in performance assessment methods focused on a constellation of abilities. Educational programs can use a range of learning models and include specific and objective performance validation of the specific competency outcomes achieved. The trend in competency based education and evaluation has been embraced in both baccalaureate and master’s programs in nursing at New York University.

The competencies for nursing care of substance related disorders reflect the consensus of American nurse educators and specialists in addictions nurse whose practices are guided by the American Nurses’ Association Scope and Standards for Addictions Nursing (2004) and the National Organization of Nurse Practitioners Standards for Psychiatric-mental Health Nurse Practitioners (2004). Competencies are developed in evidence-based approaches to alcohol, tobacco and drug problems as means of achieving patient outcomes. Evidence based approaches, as available, should be central to nursing and midwifery educational programs. Programming also includes content from the basic and social sciences, standards for care and practice guidelines developed in nursing and other disciplines.


Competencies in substance related disorders for nurse generalists

In the face of growing worldwide nursing shortage health care initiatives which expand the scope of nursing activities may be viewed as unwelcome challenges by practitioners who already feel overburdened by multiple demands and too few personnel. Therefore, competencies for dealing with substance related disorders should parallel knowledge, skills and competencies in other areas of nursing for health promotion and illness care. When the overriding competencies exist, adding knowledge about alcohol, tobacco and drugs can expand the scope of practice. For example, all basic nurses learn health assessment. In many programs, however, assessment for drug, tobacco and alcohol use is not included. Adding a nursing history for each of these drug use behaviors is a method for obtaining knowledge from which to formulate nursing interventions based on the nurse’s knowledge of alcohol, tobacco and other drug use. Within basic nursing education, didactic content and clinical experiences should support the development of nursing competencies which include:

  1. ability to identify one’s own attitudes and values about alcohol and other drug use,
  2. demonstration of knowledge of cultural differences in alcohol and drug use.
  3. identification and screening for a substance use/misuse/dependence disorder.
  4. completion of assessment of a substance use/misuse/dependence disorder through nursing and/or medical histories, and screening, noting signs and symptoms of abuse and dependence and the severity of identified conditions,
  5. formulation of nursing diagnoses of states health and illness related to drug use and dependence,
  6. delivery of nursing care including pharmacologic treatment and psychological and emotional support in acute, chronic and recovery states of illness,
  7. education of clients on health implications of use of the drugs of abuse
  8. advising on health implications, health promotion and health maintenance strategies
  9. activities directed toward the prevention of substance use/misuse disorders and harm reduction(4)
  10. referral to appropriate specialist providers for treatment and to self-help community based resources for patient/family with a substance use/ misuse/dependence disorders (4). Adapted from Naegle(10)


Competencies in substance related disorder for post baccalaureate and master’s program graduates

Nurses with additional education, certification and master’s degree education practice at the advanced level and need to be competent to intervene with the psychosocial and physiologic aspects of addiction to alcohol, tobacco and other drugs(11). The American organization, National Organization of Nurse Practitioner Faculties (NONPF), has identified Psychiatric-mental Health Nurse Practitioner competencies which provide a framework for competencies specific to advanced practice nursing care of persons with substance related disorders. Theses more inclusive competencies build upon those of the basic preparation. The competency categories below are specific for care of the client with a substance related disorder.



Content for incorporation into nursing curricula

Content basic to the development of competencies in the care of persons with substance related disorders derives from basic and advanced science courses such as chemistry, physiology, pathophysiology, and pharmacology. Behavioral and social sciences provide additional important constructs. There is now a large body of research on the etiology of alcohol and drug use, the prevention of drug related disorders, the effects of drug use on health, and the effective treatment of alcohol, tobacco and other drug dependence. Substance Related Disorder (SRD) content specific to specialty and/or advanced practice, i.e. midwifery, acute care, adult health, psychiatric-mental health theory and practicum should include research based nursing interventions, standards of nursing care for addictions nursing as well as standards for the respective specialties, and policies and practices used by nursing in the practice of caring for clients with SRDs. Newer evidence-based practices (Tables 3, 4, 5) should be included as appropriate to levels of nursing intervention and interventions appropriate to various care delivery settings should be taught and implemented in practicum/clinical seminar courses. Competency evaluation should be specific to the specialty and should be collaborative among student, preceptor and course professors. Standardized clinical performance evaluation forms should be used in all educational programs.


Models for content presentation

In recognizing the need for students to gain competencies in caring for persons with substance related disorders, schools of nursing have developed approaches to including such content. These approaches include

a. the inclusion of the requirement for learning modules about substance related disorders in courses on adult health, psychiatric-mental health, pediatric, geriatrics, etc.,

b. summer/intersession course electives,

c. a three course sequence for basic, intermediate and practicum levels of student learning,

d. integration of SRD content into existing required courses,

e. development of clinical placement (internships) in clinics, long term rehabilitation centers, detoxification units and emergency departments where students can apply theory and practice clinical competencies.

The success of these approaches is highly dependent on the support of the administration of the nursing program and efforts to emphasize the importance of nurses’ gaining competencies in this area of health care.


Teaching strategies

Teaching strategies will increase student and faculty interest and sense of mastery over substance related disorders knowledge include:

a. content development and evaluation in didactic courses (see above)

b. evaluation of clinical performance through the measurement of competencies.

Some methods for this include:

  1. OSCE Objective Simulated Clinical examinations
  2. Problem Based Learning
  3. Inclusion of evidence-based practice research applications, scientific literature searches, and protocol development.
  4. Use of case studies drawn from student clinical experiences.
  5. Consumer participation in group meetings with students, panel presentations and attendance at 12 step community based programs.
  6. Use of trained “simulated patients” who work with students in learning assessment and education of students. Using prepared scripts, actors respond to student inquiries, give feedback and assist with student learning.

Content regarding alcohol, drug and tobacco dependence treatment is available from numerous electronic and paper resources. In the last decade, numerous books and journals have been published related to the identification and treatment, as well as social implications of drug and alcohol use worldwide. There are fewer resources which derive nursing interventions and standards for nursing performance from the new evidence- based treatment approaches. Some teaching strategies which draw on available resources include:

a. use of electronic and online learning courses which are didactic and interactive,

b. accessing established alcohol, tobacco and other drug curricula such as, which has developed learning modules on specific topics, related to addiction prevention and care. Additional resources are noted in the references for this manuscript.



The use of alcohol, tobacco and other drugs is widespread throughout the world. In the Americas, such use is closely linked to health problems of addiction, cancer, cardiovascular disease, and HIV-AIDS. Nursing education programs should be preparing graduates to care for patients and families experiencing problems related to substance use as well as the illnesses with are the primary and/or secondary consequences of use. The competencies for nurse generalists and nurse specialists which support the prevention of substance related disorders and treat their manifestations have been identified and can be modified by countries and regions where patterns and health problems linked to substance use differ. The importance of using interventions which are evidence-based and modified to the cultural needs of populations remains key in the educational process.


Table 2



Table 3



Table 4



Table 5




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Madeline A. Naegle

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