Background

The purpose of a nursing model is to define the underpinning theory and concepts that guide nursing practice. To date, there is no nursing model specific to addiction services; however, several general models of nursing are frequently used in this context. An external review undertaken by Strang1 described current models used within addiction services internationally as task-oriented and reactive, with little time available for nurses to work flexibly to client need. This contrasts with the understanding that service provision should support a person-centred journey to recovery.

To address this gap, Comiskey et al.2 set out to develop an evidence-based addiction nursing model based on a cross-sectional survey of client needs and by mapping the relevant features of current models in practice. The proposed nurse-led Heathy Addiction Treatment (HAT) model targets health and recovery need at the population level, while allowing adaptation to local needs and settings.

Methods

The health-related needs of 131 clients receiving opiate agonist treatment across six Dublin drug treatment clinics were objectively assessed using the Opiate Treatment Index (OTI)3,4 structured interview tool with the General Health Questionnaire.5,6 The OTI measures a range of attributes across six domains: drug use, infectious disease risk, physical health, social functioning, criminality, and psychological adjustment. A numerical score is calculated for each outcome domain, with higher scores indicating a higher level of dysfunction. Data were collected from the study participants between May and November 2017.

In addition, relevant features from established nursing models were identified and mapped by an expert practice group through a formative review process to aid the development of the new model.

Results

Survey outcomes

Of the 131 clients that participated in the study, 66% were male and 34% were female, with a mean age of 41 years. All participants were on a substitution treatment programme with a median treatment duration of six years. Both men and women self-reported using heroin and cocaine on average more than once a week and polydrug use occurred more than once a day in the 30 days prior to interview. The most common physical symptoms reported by both genders were fatigue and energy loss, with about 70% of men and about 80% of women experiencing these health symptoms. Notably, the study reported a mean psychological adjustment score of 11.07 for women and 7.59 for men. Given the recommended cut-off point in this outcome domain is a score of 4, mental health was therefore identified as a priority need for clients in addiction nursing services. 

Nursing models

A review of current nursing models by expert practitioners determined that elements of three key models were relevant to the development of the addiction nursing model in this study. The group proposed to draw from the BRENDA model,7 which represents a biopsychosocial approach of medical management combined with a series of short and structured discussions between the client and practitioner; the FRAMES model,8 which focuses on brief interventions to initiate behavioural change in a single measurable outcome; and the Tidal model,9 which works to promote mental health and empower clients to lead their own recovery.

Healthy Addiction Treatment recovery model

Informed by the client assessment outcomes and the objective review of seminal nursing models, a collaborative nurse-led hybrid model was proposed. The conceptual HAT model places individual clients at the centre, while assessing health and recovery need and measuring impact at the population level. A manual and flowchart were developed for piloting of the model in practice and staff were allocated a working caseload of volunteering clients. Mental health was identified as a priority need for the participating client group on development of the HAT model; however, for wider implementation the model can be adapted and applied to the greatest nursing need determined in varied client cohorts and environments.

Conclusion

From this study the authors recommend the first nursing model specific to addiction services. The HAT recovery model is a practical and measurable approach to address objectively identified need and can be implemented within existing addiction service structures. Greatest nursing need is prioritised by directing nursing staff time towards client-focused tasks and eradicating entrenched practices. As the model is implemented over time, services can increase capacity in this approach and establish procedures and evaluation processes contextually appropriate to the local setting.

1   Strang J (2011) Recovery-orientated drug treatment: an interim report. London: National Treatment Agency for Substance Misuse. https://www.drugsandalcohol.ie/15524/

2   Comiskey C, Galligan K, Flanagan J, et al. (2021) The healthy addiction treatment recovery model: developing a client-driven, nurse-led addiction nursing model. J Addict Nurs, 32(1): e11–20. https://www.drugsandalcohol.ie/33854/

3   Darke S, Ward J, Hall W, et al. (1991) The Opiate Treatment Index (OTI) manual. Technical Report 11. Sydney: National Drug and Alcohol Research Centre.

4   Darke S, Hall W, Wodak A, et al. (1992) Development and validation of a multi-dimensional instrument for assessing outcome of treatment among opiate users: the Opiate Treatment Index. Br J Addict, 87(5): 733–742.

5   Goldberg DP (1972) The detection of psychiatric illness by questionnaire: a technique for the identification and assessment of non-psychotic psychiatric illness. Oxford: Oxford University Press.

6   Goldberg DP (1978) Manual of the General Health Questionnaire. Windsor: NFER Publishing.

7   Kaempf G, O’Donnell C and Oslin DW (1999) The BRENDA model: a psychosocial addiction model to identify and treat alcohol disorders in elders. Geriatr Nurs, 20(6): 302–304.

8   Bien TH, Miller WR and Tonigan JS (1993) Brief interventions for alcohol problems: a review. Addiction, 88(3): 315–336.

9   Barker P (2001) The Tidal model: developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. J Psychiatr Ment Health Nurs, 8(3): 233–240.