Nov 06, 2017, By: Julie Farthing, RN, BScN , Chang Liu, RN, BScN , Valérie Mai, RN, BNI
Plein Sevrage (meaning full withdrawal) was a primary prevention project developed by six McGill University nursing students in 2016 as part of their final year’s community health curriculum. To fulfil the course mandate, this team (which included the authors) developed and implemented this sustainable health-benefiting project in partnership with an assigned community non-profit organization (CNPO) in Montreal. Through this initiative, we acquired knowledge and skills in all five domains of the entry-to-practice public health nursing competencies (Canadian Association of Schools of Nursing, 2014).
We partnered with Plein Milieu (PM), a CNPO dedicated to improving the quality of life of youth and adults dealing with issues of drug use and homelessness. Some of PM’s clients avoid seeking out conventional health-care channels because of stigma and lack of resources. We learned that one of the main challenges for PM’s outreach workers was a lack of knowledge of best practices regarding drug withdrawal. Therefore, our project sought to enhance their knowledge of withdrawal signs and symptoms and how to help their clients initiate appropriate interventions.
The time frame for the project, from conception to implementation and evaluation, was three months (January to April 2016). After we had conducted several interviews with the outreach workers and had them fill out questionnaires, our partnership with them led to the successful creation of a workshop and two tools (a pocket guide and a fact sheet) containing practical information on drug withdrawal signs/symptoms and interventions.
During our research, we found there was little evidence-based literature on drug withdrawal management outside the health-care system. For most of the drugs we looked at, the withdrawal signs/symptoms that do not necessarily require hospital admission are similar. These include fever and headache, cravings, insomnia, generalized body aches or muscle pain, change in appetite, constipation or diarrhea, sweating, nausea and vomiting, and depression and anxiety. We put together a list of basic dos and don’ts for each one. For headache, for example, suggestions include applying cold compresses as well as taking acetaminophen and ibuprofen to relieve pain. The list was the beginning of our fact sheet.
After determining what to include in the materials, we drew on selected models, including the population health promotion model (Stamler & Yiu, 2012) and the train-the-trainer approach (Diem & Moyer, 2005), to ensure our project goal would be reached. We hoped that training the outreach workers on drug withdrawal management would allow them to transfer the knowledge to other outreach workers and their clients.
Using progressive inquiry questions (developed by our team) for the initial interviews with PM’s outreach workers helped us determine that drug withdrawal management would be the project’s focus. With this method, we were able to identify a priority issue they wanted to work on (Diem & Moyer, 2005). Indeed, the outreach workers voiced concerns about situations where their clients would attempt to quit drugs all at once and would try homemade remedies to reduce withdrawal symptoms and to avoid medical monitoring. The outreach workers feared this behaviour would lead to drug abuse relapses and dangerous health outcomes. They also mentioned their lack of knowledge and the absence of tools related to the self-management of drug withdrawal.
During the development of the workshop, pocket guide and fact sheet, the outreach workers used quantitative and qualitative questionnaires we had developed to review the tools and ensure that the content, layout and readability were tailored to their needs as well as those of their clients.
Fundraising to support our project was one of the learning objectives for this assignment. We organized a bake sale on McGill University’s campus and launched an online campaign to fund the printing of the pocket guide and fact sheet. These activities were very successful, and we donated a budget surplus of $712 to PM on the day of the workshop (March 23).
To recruit workshop participants, PM’s clinical coordinator and our team sent e-mail invitations to the outreach workers at PM and to those working at other CNPOs in the Montreal area. A total of 25 outreach workers indicated their interest. However, there were 12 attendees on the day of the workshop.
The two-hour workshop was held at the PM headquarters and featured a PowerPoint presentation on our tools and findings. We outlined drug withdrawal signs/symptoms and interventions with respect to four common classes of abused substances the outreach workers had identified: stimulants (e.g., nicotine, cocaine, methamphetamines, caffeine, energy drinks), depressants (e.g., alcohol, GHB, opioids), hallucinogens (e.g., ketamine, ecstasy, PCP, psilocybin, salvia) and anxiolytics (e.g., benzodiazepines).
We distributed the printed tools at the end of the workshop. The pocket guide, created for the outreach workers, provides a summary of the information presented during the workshop. The fact sheet [PDF, 777.5 KB], intended for the outreach workers’ clients, outlines the common signs and symptoms of drug withdrawal as well as self-management interventions. It is important to note that in these materials we emphasized consultation with health-care professionals as an essential intervention.
The main objectives for the workshop were that most participants would be able to recognize at least four physical signs and symptoms as well as two psychological signs and symptoms of drug withdrawal and identify two intervention strategies. We also hoped that most would want to include the pocket guide in their fieldwork equipment and distribute the fact sheet to clients.
To measure the effectiveness of the workshop, we asked participants to fill out a quantitative and qualitative questionnaire at the end of the session. Their responses showed that all but one of our objectives were met. Some of the outreach workers from other CNPOs were not convinced that the pocket guide should become part of their regular fieldwork equipment. However, all of the attendees from PM responded that carrying a pocket guide would be useful for their work. For the most part, the actual results surpassed the expected outcomes.
The conception phase was challenging given the scarce information and absence of similar tools in the literature. It would have been beneficial to have had more time to scrutinize the grey literature related to drug withdrawal management. As well, we might have been able to access data collected by health-care professionals and counsellors in addiction services. Obtaining hands-on information and first-person perspectives from these groups could have enriched the content of the tools.
The actual workshop attendance was lower than expected because some outreach workers were at a high school on that day for an emergency intervention. In hindsight, we should have played a more proactive role in recruiting other participants by making phone calls or delivering invitations in person.
The authors presented the project at the October 2016 Canadian Health Workforce Conference, held in Ottawa. For this poster presentation, we translated the pocket guide into English. Both tools were now bilingual and available to a larger part of the community. During the presentation, health-care professionals from several provinces expressed interest in using the tools with their students and clients. This result shows that small-scale undergraduate student projects can have a big impact on community health.
Following the conference, the Ingram school of nursing at McGill University asked for the poster and put it on display in its nursing community.
We understand that outreach workers from PM are continuing to use the pocket guide and the fact sheet, which we had made available as PDF documents.
All in all, our team was pleased with our contribution to raising awareness of a less-recognized, yet ever-present, health issue and to inspiring other health-care professionals to pursue further research.
This project would not have been possible without the great help and support of Plein Milieu’s clinical coordinator, Ann Lalumière, and her devoted team of outreach workers. We also want to thank professor Françoise Filion for her constant guidance on the project along with the other members of the team: Samantha Desjardins, Matthew Guerrera-Kotsoros and Marion G. Dubuc. Finally, we want to thank all those who personally donated to the project in some way.
Canadian Association of Schools of Nursing. (2014). Entry-to-practice public health nursing competencies for undergraduate nursing education. Ottawa: Author.
Diem, E., & Moyer, A. (2005). Community health nursing projects: Making a difference. Philadelphia: Lippincott Williams & Wilkins.
Stamler, L. L., & Yiu, L. (2012). Community health nursing: A Canadian perspective (3rd ed.). Toronto: Pearson.
Julie Farthing, RN, BScN, is a trauma-surgery nurse at Centre hospitalier universitaire (CHU) Sainte-Justine, in Montreal.
Chang Liu, RN, BScN, is an intensive care nurse at Montreal General Hospital, MUHC.
Valérie Mai, RN, BNI, is an intensive care nurse at Hospital Santa Cabrini Ospedale (HSCO), in Montreal.