Tom RN, NRC

First I'd suggest that we look at our language. Referring to individuals by their diagnosis perpetuates forms of othering such as stereotyping, stigmatizing, discrimination. This type of depersonalizing is usually a symptom of a systemic issue, so I won't point out anyone in particular. That said we should not let under staffing, lack of educational opportunities, and inadequate working space turn us against the persons we care for. That said I have felt the frustration myself and have had to provide care that left me feeling burnt-out, inadequate, and angry. It sucks. Separation of client based on diagnosis is typical practice and makes sense in many cases. For example detox. There are acute clients on a detox who need specific assessments and intervention that would not apply to most other clients. Another example might be an acute psychiatry where again specific assessments and interventions tend to take place. The problem of course is that a ever growing portion of our clients are dual diagnosis, which means aside from creating a enormous amount of dual diagnosis beds we are stuck dealing with an enormous increase in the complexity of the people we are caring for. This increase in complexity puts strain on every aspect of the health care system, but especially those on the front line (both the care providers and those they care for). I wonder if we should not take some of the advise we so often give our patients, and focus on our part of the problem and what we can change.

I work in Nova Scotia. Canada and our ratio is 3:10 with the three being 1-2 RN and 1-2 CA. That is during weekdays then we drop to 2:10 weeknights and weekends. Tom

I also agree with Tom7044, but I do my CIWA every two hours for the 6 hours and then increase the time depending on what I'm seeing. The assessments are as much art as science. You will develop a sense for what is actual withdrawal over time. In the beginning just get lots of input from more experienced staff. That said I'm sure we all have a few tactics we use like doing watching patients as they interact with others, giving them an drink of water so we can watch their hands, gauging their response to alternate therapies, and assessing patients at odd times (when I first started I found a patient doing push-ups to ready himself for the assessment). Tom RN, NRC

The questioned posed is is alcoholism a disease or choice not if alcoholics are responsible for their actions. Alcoholism fits the disease model, is recognized as a disease internationally, and can be treated. captainmeowbot if you have any credibility as a nurse, if indeed you are, you would admit that your objectivity in this matter has to be questioned. It seems more to me that you are using this forum to deal with your personal issues, because rather than engaging the entirety of any one persons response you pick out one or two words and twist them into something you can attack. You have obviously been hurt by someone with a substance use issue. I hope you get to work that out at some point, likely though you will just redirect some of your anger and hurt back at my post which is fine. The burden of proof of fitting addiction to the disease model has been met, now those of us in the profession just have to plug away at till the rest of medicine and society catches up. Heck I hear there are still people who think the world is flat. If you are truly interested in educating yourself I could post some great links on the matter. Cheers Tom RN, BScN, NRC

I think that saying alcoholism is a disease you choose is a bit off. Alcoholism like all addiction is a disease of choice. What I mean when I say this is that addiction is a disease of the very areas of the brain we use to make our choices (specifically the reward pathways running between the mid-brain and cortex) What people have to realize is that it is not the drug use that determines whether or not the disease process of addiction is present, it is craving. Drug use is part of the symptomology, and like many diseases just because one symptom is missing does not mean the disease is not present. It would be like saying because a diabetic does not eat sugar he does not have diabetes. The presence of craving is one of the key factors of addiction being classified as a disease. The addict has no choice about whether to crave or not. Cravings can be triggered by things outside the addicts control. For that reason addiction is not a choice. Of course the idea of choice itself is a lot more complex than most believe. In addiction the the process of choice has been contaminated far before the information ever reaches the cortex. The disease model is very simple 1. Organ 2. Defect 3. Symptoms Diabetes as disease 1. Organ= Pancreas 2. Defect= Death of islet cells/ no insulin 3. Symptoms= elevated blood gluc, blurred vision, coma, ect. Addiction as a disease 1. Organ= Brain 2. Defect=Physical changes in the reward, learning, choice pathways 3. Symptoms= Craving, persistent use despite negative consequences, ect.

I had almost forgotten about this post, but cannot resist posts with big words such as sanctimonious. I will assume you mean it as obsolete rather than a pios hypocrite. Let me start by saying that I would not suggest either of a nurse who is fresh out of school. Likely her knowledge is current and stance is one of unknowing and openness. I fully agree that her initial reaction was based on her perception of patient safety. I don't doubt that the patient could have been over sedated. What I called into question was her rational for the action she took. Was the problem that the drugs were available, or that they were given? If it is that they were available then she took the right action (assuming that it was the NP who ordered the meds in the first place). If it is that they were given then she ought to have, as I mentioned earlier, sought the rational of the nurse for giving the meds she did. Being able to do this is a crucial part of a young nurse's development (in my mind as important as being able to admit what they do not know). As for moral residue I mentioned that in direct response to "She is driving me NUTS but now I feel bad too- did I do the right thing". Of course moral residue has nothing to do with actual right and wrong, but rather our perception of how we act in relation ethical self perception. Only she knows if this was in fact the case. Maybe she'll post again. I love hearing other prospective on the profession. Oh and to that end thanks for the post. Tom T

In all honesty I think the ideal would be if you could split your time between the two. I think psychosocially speaking you are building on many of the same skills needed to work in a detox, and I think your experience there will serve you and your patients well. What you are likely lacking in both the psychosocial and medical part of detox nursing is acute experience and skills. You might try getting on casual on a med floor. Ask for a good chunk of orientation and take advatage of all the free training they offer. Good hospitals have in-services and refresher every other week or so. I hope that helps. Tom T. RN, NRC

That was completely my bad. I missed a key word. Oh well no harm done other than my ego, and it has seen worse. Other than the rhetoric about LTC I think my answer is about the same. I really think that some time on a medical unit would be both accessible and useful in reaching your goal. You might still look at the co-occurring disorders course I mentioned as well. It is quite significant in content, counts for up to 27 CE hours, and as I mentioned is free (they ding you $25 for the CE's, but ifyou wait till the end you only pay the 25 once). Thanks for not raking me over the coals on my blunder. Tom T, :uhoh21:

First of all I agree with MentahealthRN that experience in the areas that she mentioned would help, but I think your next question would be how do you transition to them with little to no acute experience? A bit of a catch-22. So instead of focussing on that lets look at it differently. Geriatrics is an amazing area of nursing, but is often undervalued for the complexity of nursing that it involves. The reality is that as a LTC RN you probably have more transferable skills than an ER nurse when it comes to working in a detox, but unfortunately that is not the perception most people have. In my mind the transition for you is about 15% skills, 20% education, and 65% marketing. Since I just had my coffee and feel a little frisky I’m going to draw you a little map that I think would be the shortest distance between where you are and where you want to be. To do this I am going to assume that you are a great LTC RN who is leaving because she feels like she needs a change in her career, not an old crotchety burnt out bag who’s fed up with the BS back at the home. LOL. 15% Skills Strengths- Relational practice (finding the join, coming alongside, meeting people where they are at, maintaining a therapeutic relationship, and counselling), psychosocial assessment and care, organization, multi tasking, maintaining continuity of care, careplanning, multidisciplinary approach to care, ect... Weakness- Acute medical assessments and care, dealing with manipulative clients (you may think you have but just wait), acute mental health issues (as mentioned, co-occurring disorders are the norm now not the exception), and others Suggestion- A medical unit might be the best bet as your geriatric experience would be seen as a strength. At the same time would get you feet wet and refresh your skills. In a perfect world you would be in a hospital with a psych unit or detox for education part of the plan. 20% Education- 10%- It is my belief that it would worthwhile for every nurse to take a generalized course on addiction. I believe that addiction is pertinent to all areas of nursing yet is one of the gaping holes in our knowledgebase. 10%- As mentioned co-occurring disorders are now the norm in addictions, so if addictions is your area of nurse I believe it is negligent to practice without some understanding of them. The University of Southern Florida offers a free online self-paced course which you can for a small fee provide CE’s. Bang for your buck it is probably the best out there, but the content is starting to get a little dated and it is minus a practice component that would get your foot in the door of a detox. 65% Packaging When you apply to work on a detox your resume should be specific to the work (i.e. emphasize your strengths in relational planning, working with families, counselling, leadership, teamwork, careplanning, critical thinking.) You would be surprised how much of a difference this alone makes. If you struggle with resumes then get a professional resume writer to help you. It is money well spent. Don’t ever use the words only or just in describing what you do. You are a nurse which means you are one of the most sought after professional on the planet. You have an enormously transferable skill set and the ability to learn just about anything you put your mind to. If you added a bit of medical experience and the education I mentioned to your resume I think you'd be quite marketable. If you have a passion for addictions we’d be lucky to have you. Well the coffee has worn off and this seems to be getting a bit wordy. Good-luck and I can’t wait to read the rest of the posts. Tom T RN, NRC

To who it concerns, First I would like to apologize for the delayed response. In looking back at my post I believe it reads "The assumption" rather than "your assumption", but if you took that personally then again I apologize for not being clearer in my language. If you read the other responses though I think you will agree that the assumption does exist. My point was and is that this assumption/generalization/stereotype of recovering addicts is counterproductive in our field. You provided us with very little information other than that you have a few years experience in "med/surg, ltc and homecare" and that you are "in recovery" with a " passion for helping my fellow addicts/alcoholics". Now if you asked if your experience in med/surg, ltc, and homecare would help or hinder your chances "being able to perform the job effectively" I could see making some assumptions in regards to transferable skills and approaches, but that is not what was asked. You asked if being in recovery would help or hinder "being able to perform the job effectively". Because I could not answer your question without making sweeping generalizations about recovering addicts (I know nothing about your recovery or you as a person) I thought it best to pose a few questions that seemed to be getting overlooked. Again I apologize if the language I used caused you to take the questions personally. It also seems as though you perceived some sort of negative connotation in my use of the word NEED when I asked why you felt the need to do more. Sorry if lack of clarity caused you to take this statement in a way other than it was intended. When I used the word need I meant it in the psychological form where " need is a psychological feature that arouses an organism to action toward a goal, giving purpose and direction to behaviour", or simply the upper half of Maslow's Hierarchy of needs triangle. I hope this helps. To clarify one last thing it is not that a nurse in recovery cannot be a great addictions nurse, it is that being an addict and a nurse does mean you will be a good addictions nurse. The reason I said that I was worried for both you and your patients was that your questions were posed in a way that perpetuates generalizations and stereotyping in an area of nursing that has seen it's population so discriminated against as a result. What has worried me further is how many of my colleges participated without saying something. Who knows maybe I'm just an idealist who over analyzes things. Good-luck with your career Tom T RN, NRC

LOL. I was finishing my degree with six months of remote ER nursing in on the North end of Vancouver Island which had a large First Nations population. It was totally by accident that I started working with patients with addictions. The lack of knowledge and proper protocols in the ER made the work harder, but even then something just felt right working with "those frequent fliers". Now I love the ups and downs of addictions. My patient’s resourcefulness never ceases to amaze me. Who knew you could make hooch out of OJ, sugar, and bread crust. Just amazing, lol. I would say that one of the key traits to being able to do this work is being able to value he relational aspect of nursing as equally as important as the medical. The other is being able to find reward in small successes. I feel lucky to have found something I love and not to have settled. If you have any specific questions i'm always open to an e-mail. Tom T RN, NRC

The question you ask is enormously complex. Further just the way it is posed makes me worry for both you and the patients. The assumption that a recovering addict can safely relate to someone with active addiction better than someone who is not recovering shows a lack of insight into the complexity of relational capacity and addiction. For example is a person with personal experience with addiction more or less likely to be able take a stance of unknowing or non-judgement? Who is most likely to give care or advice based on best practice rather than personal thoughts, beliefs, or experiences? Who is more likely to struggle with being able to leave work at work? I guess the question that stems from there is; what is the risk to the recovering addict? Will the constant exposure to triggers decrease or increase his/her chance of relapse? I don't think that the question should be would your experience help or hinder your chances of getting a job, but rather is this what would be best for you and the patients? Is the risk to you and them worth it for you and them? If you are involved in AA/NA then you are already helping in a way that many cannot, by example. Why do you feel the need to do more? Tom T RN, NRC

there is no denying that our healthcare systems are different, and likely many of the laws. i can't speak to all the different drug laws, but benzo's are a targeted substance in canada. that means a prescription should be needed. this is a link to a more info on it if you need something specific. http://laws.justice.gc.ca/eng/sor-2000-217/index.html drug addiction is likely much the same here with the acceptation that we have less people overall. as i’m sure you are aware addiction tends to follow the social determinants of health. populations that are poorer, less educated, oppressed, or have less access to resources tend to have higher rates of mental health and addiction issues. in canada our first nations populations is struggling severely, and with good reason. the amount of cultural genocide that has occurred here is one of our greatest disgraces, but that is another conversation altogether. tom t. rn, nrc

sorry for the confusion. i am a canadian nurse rehabilitation counsellor which means i have a four year degree (bsn) and then further education and certifications specifically in the area of addictions. much of what i do medically is covered under delegated medical functions. "delegated medical function: a procedure/treatment/intervention that falls within the practice of medicine (e.g., adjustment of insulin dosages, initiation of continuous epidural infusions, insertion of chest tubes, harvesting of saphenous veins), however, in the interest of client/patient care, has been approved by the regulatory bodies of both medicine and nursing to be performed by registered nurses with the required competence (i.e., certification)." link here so other than the united states part the answer to your question is yes, but who and what i "diagnose, admit, treat" is very specific and clearly defined. for anything that is not within our scope (or is even suspicious) we have an amazing support team of physicians and pharmacist to call 24/7. although we try to keep the 3am calls to a minimum. i hope that clears things up a bit. tom t. rn, nrc

it's impossible to give a real answer here regarding pain control for lack of information (i.e. pain scale, amount and frequency of meds given prior to your assessment, ect). for that reason i will look at the part of your post that deals with your perceptions and reaction. the fact that the patient has an addiction history is not all that relevant because the prn's are based on nursing assessment. whoever the doc was likely was just making sure that he gave the nurses on duty the tools they needed to control this woman's pain. if your suspicion was that the woman was being over medicated with prn's then common practice would be to talk with the administering nurse or nurses about her/his rational for giving the med. what i am saying here is that if the patient was indeed over medicated the problem was not that a prn was available but rather that it was given. it seems that all that was accomplished by the route that was taken was that staff following ended up with fewer tools to do their job. your actions and wording in this post suggest to me that this was an emotionally charged and ethically challenging experience for you. i believe that at the core of this issue was a concern for the safety of your patient, but i wonder if the feelings you are having now might be that at some level you suspect that your perception and reaction may have been clouded by the stigma and stereotype that addiction carries. the fact that you posted here suggests to me that you are caring around some moral residue, but i also think by looking for input from your peers you show maturity beyond your experience and a true passion to be the best nurse you can. keep asking questions it is the sign of a good nurse. tom t. rn, nrc

hello my name is tom and i am a nurse rehabilitation counselor at a detox. where i work patient ratios can range anywhere from 5-10 patients to one nurse. we also usually have at least one ca on as well. we decide on how many admits to do per day based on the complexity of each case. on average we admit about three per day, but it really ranges between 2-5. where i work the nurses tend to do more one on one work when it comes to counseling, but we do ensue that clients participate in groups as appropriate. hope tis helps and feel free to message me. tom t. rn, nrc

As most people in the field will tell you mental health and addictions go hand in hand (co-occurrence runs around 50%). If you want to get into the field look at courses that address this issue. The Univesity of Southern Florida offers a course that is free to take but cost money to get credits for. Here's the link http://mhlp.fmhi.usf.edu/web/mhlp/tdetail.cfm?id=4 Of course there are many others this is just one of the ones I have taken and thought it might give you a bit of a leg up. Tom T. RN, NRC

I guess I should start by saying that I am an NRC which is a Nurse Rehabilitation Counselor. Where I work we work under Deligated Medical Functions which means we assess, diagnose, admit, treat, and discharge without a doctors order. I guess what I'm saying is that the RN's role varies greatly in addictions. In cases like where I work nurses may take on a wide range of roles that include both medical and psychosocial aspects of patient care or as others have pointed out they may specialize in a paticular area of care. Addictions is never boring and the relational aspect of care can be intense, challenging, and very rewarding. I would suggest doing a bit of self reflection about why you want to get into addictions. It is no place for burned out old nurses or those just looking for something less physical. This is an at risk population that are stigmatized, miginalized, and stereotyped by the majority of the healthcare system. We need people with a high degree of passion and compassion in this line of work. It is not for everyone, but for the right people it can be an amazing career path. Tom T RN, NRC