RN counseling guidelines

[Anagray, BSN]

Is it in the scope of nursing practice to counsel a patient on substance abuse?

I have incidentally identified a patient with a substance abuse problem ( habitual 24 pr more pack of beer) and elevated LFTs, interviewed him about his drinking habits, he told me he is going to quit, I advised him not to suddenly stop drinking, made an appointment for him to see a physician and referred him to a substance abuse counselor on premises ( which he declined). The counselor accused me of practicing outside of my scope of practice and reported me to my supervisor.

I feel that the counselor made a borderline defamation of character accusation.

Any throughts?

[Whispera, MSN, RN]

I encouraged cutting-down/abstinence quite regularly and often gave patients information about treatment and AA groups, as part of a job as psychiatric/CD liaison in a hospital. I didn't make appointments with physicians or call counselors, unless the patient was incapable of doing it himself. I considered making appointments and calling counselors that to be something the patient could do himself, and it would indicate it was something he wanted. Many treatment professionals won't even accept appointments from people other than the ones who want treatment. I would give info. for future reference though.

So...it was in my scope of practice to do what I did. I think as part of patient advocate and educator, you didn't outstep your scope, except maybe by making the appointment/calling the counselor, since the patient declined. Did he decline and you did it anyway?

24 pack of beer in how long??

[Anagray, BSN]

Thanks for replying ! 24 pack per DAY.

The appointment I made was not necessarily for the substance abuse but as part of his pre op physical.

I am anticipating a liver ultrasound, so I wanted to get it taken care of before he was booked.

Then, of course, the issues of DTs after surgery.

[Whispera, MSN, RN]

What's the surgery for? How is a referral to a counselor relevant to the surgery? Isn't an order required to get a counselor consultation? Why is a liver ultrasound anticipated in relation to the surgery? (just trying to tie the thoughts together)

If the doctor is aware of the drinking, as he would be, after a proper H and P, he can do lots of things to prevent DTs. It's also in nurses' scope of practice, since we do a physical assessment on admission, to remind the doctor about the drinking if he doesn't seem to know about it. DTs aren't necessarily an outcome of abstinence if other things get done to prevent them. In fact, they're highly unlikely with the right interventions before they start.

[Anagray, BSN]

This is a neurosurgery patient. Typically PATs want LFTs addressed before the surgery happens because of anesthesia and the amount of drugs that will be given to patient pre, intra and post op, and most commonly primary docs will order a liver ultrasound or other bloodwork to rule out hepatomegaly, hepatitis, etc. The physician was not in the office when I interviewed the patient in preparation for surgery.

We have a social worker/substance abuse counselor on site who typically provides counseling. I was going to discuss the case with my surgeon when he came in to the office but people got involved in this before I had a chance to speak with him.

[Whispera, MSN, RN]

I think it would be to everyone's benefit if the physician developed some "standing orders" for you to use, as needed, depending on which situations you're faced with. That way you couldn't be accused of being outside scope of practice for a nurse, and things that need to get done would still get done. You'd still have to speak to the doctor because he'd have to sign the standing orders in each case.

[KristieRae71]

It sounds to me (just going on what you have stated) that you were being a pretty awesome patient advocate. I do not see why the councelor felt that way.. however it has come to my attention that coucelors and therapist don't always understand what we as nurses are and are not allowed to do. It sounds like you offered him help and he declined.

As for defamation of character… meh… just seems like that councelor has an issue. I'm sure it DID feel like a nice slap in the face though!

Best of luck!

[mtsteelhorse]

What a great nurse you are. You did NOTHING out of scope. Sounds like the counselor might have control issues, lol. You're fine.

[Meriwhen, ASN, BSN, MSN, RN]

IMO, you didn't step out of your scope of practice: you did what was necessary to help ensure the patient's safety preoperatively as well as afterwards with the education and referral.

I agree with the PP: sounds like the counselor might be a little "territorial."

[darrell]

I work for New York State in communi mental health and I provide primary psychotherapy and substance abuse counseling. I have a BS in counseling studies and an MA in H&W focusing on coaching behavioral change.

I use Acceptance and Commitment Therapy (ACT, pronounced like the word), Dialectical Behavior Therapy (DBT), and Motivational Interviewing. My focus is mostly on the behavioral change coaching.

ACT-Related Nursing (ACT-RN) | Association for Contextual Behavioral Science

[CASTLEGATES]

I would let the counselor know she needs to work on acceptance of what is (versus life as she would like it to be). We make referrals and advise patients what to do in order to promote health. What a catty thing to do by reporting you to your supervisor. I assume that counselor was going through a divorce or her husband just left (something of the sort). Don't stop what you're doing. I'd give the counselor the phone number of your state board, telling her in the future to spend her extra energy on helping patients rather than turning on coworkers.

[frosti1031]

Per Scope and Standards of Addictions Nursing Practice (2004): Standard 5F. Counseling: The addictions nurse uses counseling interventions to assist patient in promoting healthy coping abilities, preventing addiction, and addressing issues related to patterns of abuse and addiction.

I have run in to this with counselors before. They don't fully understand our scope of practice, but tend to think that anything outside of administering medications and running errands for the doctor must be outside our scope of practice. Get a copy (a new edition has just been released) of the Scope of Standards of Addictions Nursing Practice. The ebook version from the ANA is very reasonably priced.