A review of the literature with recommendations for collaboration and practice
By Sara Ling
October 30, 2023
In this research article, I describe patient-initiated discharges and explore some of the reasons people with substance use disorders leave hospital before recommended by their care providers. I focus on the complexities of stigma and provide recommendations on how nurses can enhance the care they provide.
Impact of patient-initiated discharges
Patient-initiated discharges, also known as “against medical advice” discharges, make up approximately 1 per cent of all acute care inpatient and emergency department discharges in Canada (Canadian Institute for Health Information [CIHI], 2013). Although this percentage is small, it represents thousands of discharges every year. Discharges are typically designated as against medical advice when a patient leaves the hospital despite their care provider’s recommendations to stay (Alfandre, Brenner, & Onukwugh, 2017). These discharges are concerning because they have been associated with adverse outcomes for patients (Garland et al., 2013; Vallersnes, Jacobsen, Ekeberg, & Brekke, 2019) and higher rates of 30-day readmission compared to patients who have planned discharges (Anis et al., 2002; Baptist, Warrier, Arora, Ager, & Massanari, 2007; CIHI, 2013; Choi, Kim, Qian, & Palepu, 2011; Fiscella, Meldrum, & Barnett, 2007; Garland et al., 2013; Hwang, Li, Gupta, Chien, & Martin, 2003; Tan, Feng, Joyce, Fisher, & Mostaghimi, 2020).
Role of substance use and mental health
Many studies have found that people who have substance use disorders and/or mental health concerns are among those who are most likely to self-discharge from hospital (Abo-Sido, Simon, & Tobey, 2018; Aliyu, 2002; CIHI, 2013; Choi et al., 2011; Kraut et al., 2013; Kumar, 2019; Moyse & Osmun, 2004; Spooner, Salemi, Salihu, & Zoorob, 2017). Naturally, this raises the question: what makes this population more likely to initiate their hospital discharge?
Several studies have used qualitative methods to explore acute care hospitalization experiences of people with substance use disorders. These studies highlight some of the adverse experiences that can occur in hospitals that lead to patient-initiated discharges. Here is a summary of the findings:
- McNeil, Small, Wood, and Kerr (2014) interviewed 30 people who injected drugs who had self-discharged from acute care hospitals in British Columbia. Patients often reported having poor pain control, withdrawal symptoms and disruptions in medications used to treat opioid use disorder. They perceived that they were viewed as “drug-seeking” and reported being subject to searches and increased observation by staff.
- Simon, Snow, and Wakeman (2020), in their study of 15 people who had opioid or alcohol use disorders, found that people often left hospital early because of withdrawal symptoms, undertreated pain and experiences of discrimination and stigma related to having a substance use disorder.
- Chan Carusone et al. (2019) explored the care experiences of 24 people who used drugs who were admitted to an acute care hospital. Some patients’ hospital admission ended with self-discharge due to insufficient pain management and perceptions of lower-quality care compared to patients without a substance use disorder.
- Jafari et al. (2015) studied a community care setting, but collected noteworthy results about patients’ experiences in hospitals. The community care setting, which was being used as an alternative to acute care hospitalization, was providing intravenous antibiotics to treat tissue infections in people who injected drugs. Researchers interviewed 33 people (patients and staff) and reported on patient-initiated discharges as one of the outcomes of interest. The study found that patients were more likely to leave hospitals than they were the community care setting, and that some of these discharges were driven by patients’ experiences of negative treatment (i.e., stigma and judgment) from clinicians.
The role of stigma
Stigma regarding substance use disorders is entrenched in society due to historical views of substance use problems being a moral failing and a criminal issue rather than a health concern (McGinty & Barry, 2020). There are many factors to consider related to stigma:
- Patients may internalize negative views and stigma (McCradden, Vasileva, Orchanian-Cheff, & Buchman, 2019; McGinty & Barry, 2020), resulting in reluctance to access services or disclose substance use out of shame or fear of discrimination (Biancarelli et al., 2019).
- Societal stigma can permeate practices within health-care settings through policies (McGinty & Barry, 2020; McNeil et al., 2014; Wakeman & Rich, 2018) or insufficient resources allocated to addiction services (McGinty & Barry, 2020). Such policies may put nurses in the difficult position of having to surveil patients (McNeil et al., 2014; Todt & Thomas, 2021) or leave them feeling unsupported in providing care for patients presenting with substance use challenges.
- Anticipation and bias can exacerbate all of the above difficulties. People with substance use disorders may present with challenging behaviours when intoxicated or in withdrawal (Volkow, 2020). Clinicians who have had challenging interactions in the past may anticipate similar experiences with future patients, thus shaping how those interactions unfold (Hoover, Lockhart, Callister, Holtrop, & Calcaterra, 2022). Similarly, patients who have had negative experiences with the health-care system may have preconceived perceptions that can influence their behaviours during future encounters (Hoover et al., 2022).
Recommendations for practice
What can nurses do to improve the care experiences of people who use drugs and prevent early discharges from hospital? The key is breaking this cycle of mutual mistrust:
- Develop your compassion by reframing your understanding of challenging behaviours as symptoms of patient illness (Volkow, 2020). Use person-first language and acknowledge the social and contextual factors that often precipitate individuals’ substance use disorders (McGinty & Barry, 2020).
- Learn more about substance use. Education is essential to empower clinicians and increase awareness of evidence-based care of people with substance use disorders (Dowdell, Alderman, Foushee, Holland, & Reedy, 2022; McCradden et al., 2019; McGinty & Barry, 2020).
The Registered Nurses’ Association of Ontario has a clinical best practice guideline on engaging clients who use substances (Registered Nurses’ Association of Ontario, 2015). Here is a summary of what the guidelines suggest:
- Be informed about substance use disorders and how to screen for them.
- Have an open-minded, non-judgmental approach.
- Be aware of medications — such as opioid agonist treatments — used to treat substance use disorders.
- Advocate for patients if they are not receiving evidence-based medications or sufficient withdrawal management.
- Advocate for harm reduction policies and practices within clinical settings.
Recommendations for increased collaboration
It’s clear that not every nurse or clinical team will become experts in treating substance use disorders. To overcome this difficulty, consider seeking collaboration and support from clinicians with expertise in addiction treatment. Here are two strategies to achieve this goal:
- Set up addiction consultation services. Some hospitals have successfully implemented addiction consultation services, which are typically interdisciplinary teams that specialize in addictions. These teams can collaborate with other clinical teams and provide services to people with substance use disorders who are receiving care for other health conditions (Hoover et al., 2022). Such services have been shown to decrease stigma by supporting clinicians in caring for people with substance use disorders and decreasing patient self-stigma by acknowledging substance use disorder as a treatable condition (Hoover et al., 2022).
- Implement harm reduction policies and practices (Lennox, Martin, Brimner, & O’Shea, 2021; Perera et al., 2022; Sharma, Lamba, Cauderella, Guimond, & Bayoumi, 2017), including supervised consumption (Dong, Brouwer, Johnston, & Hyshka, 2020) and overdose prevention (Nolan et al., 2022). Introducing such services within hospital facilities, which requires a great deal of teamwork, may better meet the needs of people who use drugs and reduce the onus on nurses and other clinicians to police patients, as is often required when abstinence-based policies are in effect (McNeil et al., 2014).
Conclusion: take individual action
Some of the solutions I’ve listed in this article are complex and require action and investment by institutions. However, at the individual level, nurses can become informed about substance use disorders and their treatment, provide and advocate for evidence-based care, and model positive attitudes. By taking these actions, you can facilitate culture change and ultimately improve the care experiences of people who have substance use disorders.
Nurses are intimately familiar with the challenges that arise in clinical settings and are therefore positioned to make recommendations for solutions that are meaningful, realistic and practical. As nurses, we have strength in our individual voices and as a collective.
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Sara Ling, RN, PhD, CPMHN(C), is an associate scientist in the digital mental health lab and advanced practice clinical leader in the inpatient addictions services at the Centre for Addiction and Mental Health.