(65) Nurse Practitioner Treatment of Opioid Use Disorder: A Phenomenographic Study

Background &

Introduction: Nurse practitioners (NPs) are a growing portion of the healthcare workforce, with more than 355,000 NPs in the United States and over 7,400 in Canada. Although NPs are increasingly providing medication for opioid use disorder (MOUD) within primary care settings, regulatory and other barriers remain. In North America, NP prescribing is regulated at the state, provincial, and territorial level. NPs in Canada also prescribe safe supply – intended to replace illicit street opioids (and other drugs) with prescription alternatives.

The literature about how NPs learn to provide MOUD in practice, and how they experience this work is sparse. The NP role blends biomedical and nursing approaches, with a strong focus on social justice and the advancement of public health. Treatment of opioid use disorder as a harm reduction model can be argued to fall within the remit of nursing’s social contract. The concept of capability has potential to describe a level of NP practice that is inclusive, expert, and flexible; essential attributes for the provision of MOUD.

A qualitative phenomenographic study was conducted to explore how NPs providing MOUD and/or safe supply in primary care settings experienced capability development in doing this work.

Methods: Purposive and network sampling was used to recruit NPs prescribing MOUD or safe supply to patients aged 18 and older in primary care settings in Ontario, Canada, and the six U.S. New England states. The final sample included 37 individuals; nine did not meet inclusion criteria; seven withdrew or did not respond. Demographic information was collected using a Qualtrics survey. Qualitative interviews were completed with 21 participants (12 from Canada, and 9 from the United States) using Zoom. Initial interview transcripts were generated using Otter.ai software and reviewed for meaning and completeness.

A phenomenographic approach to data analysis was used to identify categories of description and their referential (overall meaning) and structural aspects. Following initial transcript review, meaningful utterances were extracted to a pool of meanings for further analysis. Provisional categories of description were assessed for their reach across multiple aspects of capability development. Following an iterative analytic process, final hierarchical and inclusive categories of description were named, described, and compared within an outcome space.

The study was approved by the Health Sciences Research Ethics Board, at Queen’s University [NURS-542-22].

Results: Study participants ranged in age from 28 – 64 years and had 1 – 24 years of NP practice experience. MOUD or safe supply experience ranged from 0.25 – 4 years, reflecting recent regulatory changes allowing MOUD within NP scope of practice. Only three NPs received training in treatment of opioid use disorder as part of their initial NP education. Treatment settings included community clinics and primary care practices, as well as NP-led and mobile clinics. The incorporation of standard opioid agonist treatments and safe supply guaranteed a range of treatment approaches and medication options.

Five hierarchical and inclusive categories of description were identified through the data analysis. The development of capability in treating OUD was experienced by NPs as a process of: A) acquiring foundational practice knowledge of MOUD; B) integrating foundational knowledge with other aspects of practice; C) evolving practice perspectives; D) adapting practice; and E) becoming expert. The first two categories (A and B) were focused on the acquisition of foundational practice knowledge, and the integration of new knowledge with existing skills and knowledge areas. In categories C and D, NP participants began to question existing practices and protocols and to adapt and customize their approaches to care, at times including intentional departures from existing guidelines. Finally in category E, NPs described a process of becoming expert, and their conceptions of capability in treating OUD became more holistic, with a focus on collaboration. Four dimensions of variation contributed to the structural aspects: role of self as NP; relationality with people who use drugs; collaboration; and confidence.

Findings must be considered within the context of the COVID-19 pandemic, which coincided with data collection. Study limitations include virtual interviews/data collection due to pandemic-related restrictions. The study focused on the NP experience; future research might consider the experience of individuals who use drugs and receive care from an NP.

Conclusion &

Discussion: Study results confirmed that, like many NPs in North America, participants had little or no basic training in treating addiction, with only three out of the 21 participants reporting any training in addiction during their pre-licensure NP education. Therefore, the development of knowledge about OUD was relevant, compared to other practice areas where NP educational preparation has historically been more robust.

As they gained confidence with basic skills and experience in working with people with OUD, NPs described evolving practice perspectives. Moving towards capability entailed both a consolidation of knowledge, and the willingness and ability to question current evidence and guidelines, critically analyze practice, and when necessary, consider treatment modifications. Mentors were important to NPs early in their work providing MOUD; those mentors continued to be valued for their perspectives and guidance on new treatment approaches, even as NPs became more capable. While leadership was not explicitly named, many participants assumed leadership roles. Leadership activities included mentoring of other NPs or students, committee memberships, development practice protocols, advocacy, and staffing of a national provider hotline. Interprofessional interactions were an important aspect of how NPs saw themselves as serving in the capacity of acknowledged expert.

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