1. Danda, Michelle MN


A less rigid approach that incorporates harm reduction and destigmatization.


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I recently had a conversation with a nursing student about the best intervention for a patient who is nearing discharge and discloses to the nurse that they will be going directly from the inpatient mental health unit to seek out illegal substances to get high. My response was along the lines of: "After doing our risk assessment, we would thank them for being honest, provide them with information about the potential risks, and tell them about services they can access for safer substance use once they get their drugs."

Figure. Michelle Dan... - Click to enlarge in new windowFigure. Michelle Danda

I was struck, as I said this, by how different my response would have been more than a decade before when I was a nursing student with little knowledge of concepts like harm reduction, trauma-informed practice, and person-centered care. The relationships I have today with patients who are stigmatized and marginalized because of substance use are vastly different from those I had early in my career when I was taught a paternalistic, expert-oriented, medical model-driven perspective. The approach has shifted from one in which I, along with the health care team, dictated the care plan, to one where I meet my patients where they are and work with them to understand their perspectives and needs.


My own learning, both academic and from people who use substances, has been transformative in my role as a nurse. I no longer view people who use substances as moral failures who need to be changed, but as people who engage in behaviors that have both risk and benefit, depending on their needs, with my role as a nurse involving an attempt to understand those needs.


Unfortunately, the stereotypical image of the substance user as a morally corrupt and fundamentally damaged person is pervasive in society. Despite antistigma campaigns, education, and the increasing visibility of alternative perspectives, the understanding of illegal substance use as always problematic persists. Near the beginning of my career, I began to question this perspective when I shifted from an inpatient mental health unit for people living with mental health and substance use issues to a community addictions program with a philosophical base rooted in harm reduction. I learned that substance use ranges from sporadic to problematic, with perceived benefits and harms.


Too often in health care, and in inpatient mental health areas, control and risk mitigation have guided care decisions. Patients are expected to live their lives exactly as health care professionals tell them to, even when patients explicitly say they will not do so. I've seen this approach result in patients simply regurgitating what the physician or nurse tells them just so they can be discharged, because they feel the clinician is either judging them or not listening to their perspective, they are afraid of getting into trouble, or they just want the clinician to stop talking. The result has been unrealistic discharge planning and staff frustration if a patient becomes symptomatic in the community and requires another hospital admission. I've sat in on complex case rounds where clinicians acknowledged the plan would fail but persisted anyway. It made me wonder why we were not changing the plan-and also question the ethics of this approach.


It took me years to learn that a more person-centered and trauma-informed approach involves listening to the patient and assessing where they are in terms of the transtheoretical model of change. No matter how much I (or the clinical team) may want the patient to be at a certain stage of action, they are going to be where they are. This shift in approach involves letting go of an investment in a patient following through with a care plan they clearly believe won't work for them. In this a deeper understanding of my role as a nurse has emerged, one in which I am in relationship with my patients rather than vainly trying to make decisions for them.