WelTec Nursing Forum

November 2009

Raine Berry

Nursing and Addictions

• Coexisting Disorders

• The Addictions Nursing Workforce

• Current Treatment Situation

• Workforce Issues

• Matua Raki Strategies

• Workforce Vision

Coexisting Problems

• Coexisting Capable

• Coexisting Enhanced

• CEP is common

Prevalence of CEPNZ MH Survey 2004 – Te Rau Hinengaro• 20.7% mental health disorder (L/T)

- 45% of these had coexisting drug disorder and/or alcohol abuse

- 31% met criteria for alcohol dependence

- 37% more than one disorder- 7.7% multiple

• 40% with substance use disorder also met criteria for an anxiety disorder and 29% a mood disorder

CEP Associated Issues

• Major impairment in role functioning

• High prevalence of chronic medical issues e.g. chronic pain, cardiovascular disease, high BP, respiratory conditions, diabetes

• Suicidal behaviour associated with increased number of disorders

• People with diagnosed mental health disorder twice as likely to use alcohol hazardously

Dependence Diagnosis in NZ Outpatient SampleAdamson et at 2006

Diagnosis Current Lifetime Onset

Alcohol 58 75 22.4 (8.7)

Cannabis 42 61 18.0 (4.3)

Opioid 15 24 22.5 (7.1)

Sedative 14 26 22.3 (7.1)

Amphetamine 20 29 20.4 (4.0)

Hallucinogen 4 19 18.9 (3.7)

1 substance 45 26

2 substances 24 20

3 - 8 substances 16 46

Coexisting Disorders in an AOD Outpatient Sample

Adamson et al 2008Diagnosis Current % Lifetime % Onset Age

Total with coexisting non-substance use/non-gambling Axis I Disorder

74 90

Major depressive episode 10 14 22.2 (14.1)

Major depressive episode, recurrent 24 30 19.2 (10.3)

Bipolar 1 disorder 11 15 17.5 (6.7)

Substance induced mood disorder 8 14 19.3 (9.3)

Obsessive compulsive disorder 20 24 16.4 (8.3)

Posttraumatic stress disorder 31 45 18.6 (11.3)

Panic disorder with agoraphobia 13 15 13.8 (10.4)

Social phobia 31 37 11.9 (7.1)

Specific phobia 22 32 8.0 (9.8)

Antisocial personality disorder 27 41

The Addictions Nursing

Workforce

AOD Workforce DemographicsAll AOD Nurses

Female 59% 82%

Median age 49 years

3% < 30 yrs

48 years

DHB 57% 85%

Pakeha

Other European

59%

16%

62%

29%

Maori 15% 3%

Pacific 3% 0%

Asian 5% 3%

Postgraduate Qualifications

All AOD Nurses

Any Postgraduate 47% 80%

Postgraduate AOD 27% 50%

Studying toward Postgraduate AOD

05% 12%

Routine Activities

Individual Therapy 88%

Comprehensive Assessment 82%

Education or other community work 82%

Brief initial assessment/triage 79%

Clinical case-management 79%

Facilitate groups or meetings 56%

Report writing 94%

Supervision of other staff 71%

Administration 71%

Management 41%

Skills nurses bring to addictions• Health education• Assessment and treatment planning• Coordination of care from assessment to discharge• Pharmacotherapy knowledge• Withdrawal management• Monitoring – health, bloods, BP etc• Crisis intervention• Risk Management• Consultation/liaison• Counselling• Documentation

Perceived barriers to nurses wanting a career in addictions

Barriers % of responses

Lack of knowledge, skills, attitudes

71

Nurses not interested 71

Stigma 59

Lack of understanding / awareness of roles

44

Pay and conditions 38

Under-resourced 21

Nursing Roles in the Addiction Context

• 85% of nurses in designated nursing positions

• Previous poor recognition of advanced practice roles

• 51% intend to work toward an advanced practice role including 30% Nurse Practitioner

• Expanded and extended practice scope

AOD Treatment Survey

AOD Treatment Position

• Many services struggling to meet demand

- detox (residential medical and social)

- youth services

- coexisting problem service

- residential programmes (incl. A&D Act beds)

Treatment Position

• Influencing factors

- Lack of new positions

- Lack of competent practitioners able to take clinical responsibility

- Doubling of referrals from Corrections since the new Sentencing Act

Workforce Issues

Recruitment

• More workers in NZ labour market will retire than be recruited over next 25 years

• Labour demand will exceed supply in AOD from 2011

• Attaining and attracting qualified and skilled staff

• Difficulty recruiting for specialist positions (detox, CEP)

Key issues• Aging workforce

- AOD age 49 in 2008, age 42 in 1998- National labour force – age 40 in 2006, age 36 in

1991

• Workforce Trends- Rise in qualification level- Rise in numbers of ‘other Europeans (6% 2004, 16% 2008, Nurses 29%) - More counsellors, fewer nurses and fewer Maori

• Retention - high turnover (41% in AOD workforce for less than 5 years)

Matua Raki Strategies

Matua Raki Projects

• Capacity Building– Forecasting– Consumer workforce

• Capability Building- Scholarships, Internships- Mobile training and short courses- MI Internships- Families with complex and challenging issues- CEP enhancement project- Responses to methamphetamine problem

AOD Advanced Practice Nursing Project

• Promote flexible post-graduate AOD/addiction advanced practice professional development nursing pathways within clinical masters programmes leading to clinical Nurse Specialist/ Nurse Practitioner that incorporate postgraduate papers

• Strengthen national nursing leadership networks, including amongst nurses on the Nurse Practitioner pathway

• Strengthen strategic partnerships with nursing leaders within workforce programmes

AOD Advanced Practice Nursing Project

• Support strategic and operation planning within the Addiction and Mental Health sector to develop the infrastructure for the implementation and ongoing support of advanced AOD/addiction advanced practice nursing roles

• Assist individual nurses with achieving / recognition of advanced practice status

Summary

• The capability and capacity of the AOD treatment sector improving however increasing demands on services continue

• Increasing the numbers in the addiction workforce not enough

• Nursing workforce needs to increase:– New dedicated nursing positions created– Pathways for Nurse Practitioners supported

• New approaches needed to:- recruitment- funding- treatment provision

Workforce Vision

By 2012• Confident and hopeful workforce • Skilled / capable specialist workforce • Skills and knowledge gained supported and utilised in

the workplace• Consumer and peer workforce well established• Increased Maori and Pacific Workforce• Advanced nursing roles well established with Nurse

Practitioners employed in each specialist service• Increased capability in PHC and allied workforces to

address addiction issues• The average age of the workforce matches the National

Labour force average • Career in Addictions attractive to graduates and school

leavers

Postgraduate AOD Courses

• National Addiction Centre

• Auckland University

Prevalence of Mental Health Disorders

• 39% of people >16 years met criteria for a disorder at some time before interview Life-time (L/T) Risk = 46.6%

• Anxiety = 24.9% L/T Risk = 28.8%• Mood = 20.2% L/T Risk = 28.4%• Sub Use 12.3% L/T Risk = 13.8%• Eating = 1.7% L/T Risk = 1.9%

Te Rau Hinengaro 2006

12 month Prevalence of Substance-Use Disorders

• 2.6% alcohol abuse; 1.3% dependence

• 1.2% drug abuse; 0.7% dependence

• 0.9% Cannabis abuse; 0.5% dependence

• Higher in Maori, Pacific, younger people, males, people with less education, less income