Recent national attention has focused on exploration of interventions to reduce the opioid crisis.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).

Scope of the Problem

The number of individuals affected by SUD, specifically alcohol and opioids is staggering, often resulting in increases in visits to the emergency department, inpatient stays, and death. Among individuals aged 12 and older, 14.5 million people identified themselves as experiencing an alcohol use disorder in 2017 (SAMHSA, 2018). In that same year, approximately 30.5 million people aged 12 or older used an illicit drug during the past 30 days; an estimated 11.1 million people misused opioids; 11.1 million individuals misused pain relievers; and heroin was used 886,000 individuals (SAMHSA, 2018).

...an average of six people die as a result of alcohol poisoning each day.In the US, the Centers for Disease Control and Prevention (CDC) estimates that an average of six people die as a result of alcohol poisoning each day (CDC, 2015). According to the National Institute on Drug Abuse (2019), more than 70,200 Americans died from drug overdoses in 2017. The statistic includes both illicit drugs and prescription opioids. The number of individuals who die as a result of drug and illicit drug use is alarming. Current statistics related to substance use disorders demonstrate not only an increasing number of affected individuals, including their family, friends, co-workers, and communities, but also the burden on healthcare providers and facilities to meet the increasing number of individuals requiring treatment in emergency, in-patient, and outpatient facilities. This is truly a healthcare crisis and one to which leaders in the nursing profession must respond through a partnership involving education, practice, research, and policy. This article will focus on the role of education in the partnership.

The lack of sufficient time and content in nursing education curricula to adequately cover the complexity of SUD has been documented...for over 50 years.The lack of sufficient time and content in nursing education curricula to adequately cover the complexity of SUD has been documented in the literature for over 50 years. Johnson (1965) identified a lack of adequate preparation and experiences as a barrier, thus preventing nurses from providing an appropriate level of care to individuals experiencing alcohol use disorders (AUDs). Hoffman & Heinemann (1987) reported an average amount of time teaching alcohol and drug content as one to five hours in all three types of programs (i.e., diploma associate, and baccalaureate) surveyed. Murphy (1989) identified a 20-year pattern of nurses who failed to attain a sufficient level of preparedness to identify and adequately treat patients with SUD during their initial education. Murphy further described the need for additional curriculum development, theory development, research, and preparation of faculty. Naegle (1994) identified gaps in nursing education regarding substance abuse and linked the role of nurses treating patients with substance use disorders with two primary objectives: to “identify alcohol related problems in patients and to refer them to treatment specialists” (p. 155). Howard, Walker, Walker, & Suchinsky (1997) reviewed multiple surveys regarding inclusion of drug and alcohol content in nursing education curricula, reporting limitations in content and time allotted for didactic and clinical experiences.

Savage, Dyehouse, & Marcus (2014) reported a cross-sectional, electronic survey of schools of nursing to determine the mean number of alcohol-related content hours; content offered; and inclusion of strategies to reduce at-risk drinking, such as screenings and brief interventions. Sixty-nine schools responded to the survey, however, three schools did not offer a bachelor’s degree in nursing. Only 39 of the eligible 66 schools provided the total hours related to alcohol-related content, resulting in a mean of 11.3 hours (SD = 8.3 hours) of alcohol-related content. Psychiatric/mental health courses included the highest amount of specific content (mean = 4.9 hours, SD = 5.03). However, 29.3% of respondents reported less than three hours of alcohol-related content in the psychiatric/mental health course (Savage et al, 2014).

The least amount of alcohol-related content hours was found in women and children’s health courses...Adult health/medical surgical nursing courses reported a mean of 2.6 hours (SD = 3). The least amount of alcohol-related content hours was found in women and children’s health courses (mean = 1.8 hours, SD = not reported) and community/public health courses (mean = 1.6 hours, SD = not reported ). A mean of 6 hours was reported for the total alcohol-related content hours computed for all courses other than the psychiatric course (Savage et al., 2014). Less than 10% of the schools required competency in screening and brief intervention. Savage et al. (2014) suggested incorporating content aimed at prevention and early intervention for risk of use. In addition, there needs to be a lifespan approach in baccalaureate program curricula addressing the needs of individuals experiencing alcohol use disorders. Other recommendations for a lifespan approach across a baccalaureate program curriculum included genetics; neurobiology of alcohol addiction; prevention of AUDs; screening and brief intervention for at-risk alcohol use and AUDs; withdrawal management; treatment for AUDs; alcohol-related health consequences; and potential legal and ethical issues (Savage et al., 2014).

The National Council of State Boards of Nursing (NCSBN) surveyed 6000 candidates who successfully completed the NCLEX-RN examination during the time period of April 15, 2016 through March 15, 2017. Survey participants (55.0%) described the client population as acutely ill (55.0%) and noted 27.2% of the client population had behavioral/emotional conditions (NCSBN, 2018).

The shortage of content hours related to alcohol and other substance use disorders in baccalaureate curricula has consequences.The shortage of content hours related to alcohol and other substance use disorders in baccalaureate curricula has consequences. Newly licensed registered nurses may lack sufficient knowledge regarding the care of individuals who experience alcohol use disorders. The shortage of existing and newly licensed registered nurses and advanced practice nurses with expertise in treating individuals with alcohol use disorders threatens the level of care required by this population. Nurse educators often lack sufficient expertise in alcohol use disorders thus diminishing the potential for strengthening curricula.

Nurse educators often lack sufficient expertise in substance use disorders, thus diminishing the potential for strengthening curricula.To initiate curricular change, a perceived need to change is essential. It is well established that current approaches to curriculum design in baccalaureate nursing education programs often lack sufficient experiences and depth of knowledge regarding substance use disorders. Kane (2012, 2015) described essential competencies for registered nurses related to psychiatric and substance use disorders. She leads a core group of nurse educators and practitioners who continue to advocate for the development of a set of competencies for nurses who provide care for individuals experiencing substance use disorders.

Challenges of changing nursing curricula include time allotted for the content and the environment in which it is delivered.An expert panel (the Psychiatric Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric Mental Health Substance Abuse) developed the Essential Psychiatric and Mental Health and Substance Use Competences (2012). The guidelines include the following core nursing content areas: growth and development; neurobiological basis of care practice; pharmacotherapeutics and basic principles of pharmacology; communication theory and interpersonal relational skills; clinical decision making; patient care roles; healthcare settings; cultural ethnic and spiritual concepts; health promotion and illness prevention; concepts of chronic illness; ethical and legal principles; vulnerable populations; and nursing research. Challenges of changing nursing curricula include time allotted for the content and the environment in which it is delivered.

One Possible Solution

Exposure to individuals experiencing SUD in different settings will allow nursing students to build competencies throughout their educational experiences.Expanding the time allotted for instruction about SUD in nursing education programs may offer part of the solution to the substance abuse crisis. Exposure to individuals experiencing SUD in different settings will allow nursing students to build competencies throughout their educational experiences. This diverse exposure will also increase students’ awareness of the impact of SUD on individuals in multiple settings across the lifespan. Conceptual frameworks provide an integrated approach throughout the curriculum to address student learning needs. Fink’s (2013) integrated approach provides a conceptual framework suitable to teach students about substance use disorders. Fink’s taxonomy creates a lifespan approach and does not limit teaching or learning to one specific course, but rather as an ongoing opportunity for competency building.

Fink’s Integrated Approach
Fink (2013) describes a taxonomy of significant learning designed to create learning experiences that are “engaging” and “high energy” but also result in “lasting change” and “value in life” while preparing students for the “world of work” (pp. 8-9). Fink (2013) created the taxonomy of significant learning for each course with the following intersecting major categories: foundational knowledge, application, integration, human dimension, caring, and learning how to learn. Fink provides verbs and learning goals for each category of the taxonomy.

Foundational knowledge involves the ability of students to “understand and remember specific information and ideas” (Fink, 2013, p. 34). The section focuses on content information (i.e., remembering and understanding), thus creating a deeper understanding about the subject. Foundational knowledge is the basis of other learning (Fink, 2013). The second category, application, is “[l]earning how to engage in various kinds of thinking (critical, creative, practical) is an important form of application learning but this category of significant learning also includes developing certain skills or learning how to manage complex projects” (p. 35). Application “…allows other kinds of learning to be useful” (p. 36). Integration occurs “[w]hen students are able to see and understand the connection between different things” (p. 36). Integration provides intellectual power (Fink, 2013).

Human dimension results “[w]hen students learn something important about themselves or about others, it enables them to function and interact more effectively” (p. 36). Human dimension creates an understanding about the human significance of learned content (Fink, 2013). Caring results when “…. a learning experience changes the degree to which students care about something. This may be reflected in the form of one’s feelings, interests, or values. Any of the changes means students now care about something to a greater degree than they did before or in a different way” (p. 36). Students’ ability to care about something creates energy for learning (Fink, 2013). Learning how to learn describes how “…. students can learn something about the process of learning itself. They may be learning how to be a better student, how to engage in a particular kind of inquiry or how to become a self-directed learning” (p. 36). Learning how to learn allows students to effectively continue the learning process (Fink, 2013).

Synthesis of Essential Content
It is important to [also] consider...the teaching strategies to teach this content regarding substance use disorders.Blending the recommendations of the Psychiatric Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric Mental Health Substance Abuse Expert Panel (2012) with Fink’s (2013) integrated approach and taxonomy of significant learning provides a framework to change baccalaureate nursing education about substance use disorders. It is important to consider not only the content and the time allotted, but also the teaching strategies to teach this content regarding substance use disorders. The following tables (Tables 1-4) list the core nursing content and synthesize essential PMHN content; learning outcomes defined as clinical competencies; and the emphasis from Fink's (2013) taxonomy of significant learning.

Table 1. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN) †+

Table 2. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued †+

Table 3. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued†+

Table 4. Guidelines for Undergraduate Education in Psychiatric Mental Health Nursing (PMHN)-continued †+

**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.

Download tables here

Conclusion

The number of individuals experiencing SUD requires a response in terms to create nursing educational opportunities to strengthen the workforce.The number of individuals experiencing SUD requires a response in terms to create nursing educational opportunities to strengthen the workforce. Nurse educators need to optimize the current attention on the opioid crisis as an opportunity to strengthen nursing curricula in the areas of SUD. Fink (2013) encourages educators to recognize the need for learning-centered approaches. He defined learning in terms of change, noting that, “[f]or learning to occur, there has to be some kind of change in the learner. No change, no learning. And significant learning requires that there be some kind of lasting change that is important in terms of the learner’s life” (p.34). His integrated approach with the taxonomy of learning was designed to be interactive, not hierarchical. Each type of learning informs other areas of learning, creating a synergistic effect. Utilizing the Psychiatric Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric Mental Health Substance Abuse Expert Panel (2012) and Fink’s (2013) approach provides a curricular model to inform change in this important area of nursing curriculum.

Author

Marian L. Farrell, PhD, PMH-NP, BC, PMH-CNS, BC, CRNP
Email: marian.farrell@scranton.edu

Marian L. Farrell is a professor of nursing at the University of Scranton located in Scranton, PA. She is currently certified as both a psychiatric mental health nurse practitioner and psychiatric clinical nurse specialist. She has experiences teaching psychiatric mental health nursing at both the undergraduate and graduate levels.