Opioid use disorder (OUD) remains a national epidemic since officially being proclaimed a public health emergency in October 2017 (U.S. Department of Health & Human Services, 2017). According to the Centers for Disease Control and Prevention (2019), prescription and illegal opioid use is the main factor in overdose deaths, with 115 Americans dying daily. The number of opioid-involved overdose deaths has increased fivefold from 1999 to 2016, with a total of 42,249 deaths in 2016 (Hedegaard, Warner, & Minino, 2017). The sheer number of deaths from opioid overdose is frightening, as is the number of families who become secondary victims of addiction.
Secondary victims can happen in the earliest stages of life, such as during pregnancy, which can result in neonatal abstinence syndrome (NAS). The number of infants born with NAS continues to rise and is as high as six for every 1000 births (Rappleye, McHugh, & Farrow, 2017). Approximately 8 million children younger than age 18 live with an adult who has an addiction to opioids; a majority of these children are younger than age 5 (Blozen, 2013). Research shows these children often live in an unstable environment and are at a higher risk for abuse and becoming a drug abuser later in life (Lipari & Van Horn, 2017).
The effects of OUD are not solely focused on children, but rather, OUD affects all of the addicted person's relationships (Luke, Redekop, & Jones, 2018). MentalHelp.net (n.d.) defines substance use disorder as a “pathological set of behaviors” that fall into four categories: impaired control, social impairment, risky use, and pharmacological indicators. An individual with OUD will continue to use the substance regardless of work issues, money issues, arguing or violence with those close to them, neglect of those same people, losing relationships, and not meeting household responsibilities, which affects countless others (Luke et al., 2018; MentalHelp.net, n.d.). Due to the multitude of people affected by OUD, most health care professionals are likely to interact with people affected by OUD in some fashion.
The reality is that OUD will touch the careers of future generations of nurses no matter their chosen work setting. The incorporation of OUD in undergraduate nursing education is critical for the preparation of the next generation of nurses to address the current and future challenges caused by the opioid epidemic. Innovative and interesting methods are needed to incorporate this information into the already full nursing curriculum. The unfolding case study is one modality to incorporate opioid education into the curriculum.
In an unfolding case study, nursing students receive a portion of the information and must assess and ask questions to receive additional information to make a clinical decision and progress through the scenario (Carter & Welch, 2016). The National League for Nursing (NLN, 2020) describes the unfolding case study “as evolving over time where further information is gained at each encounter.” Research has shown the unfolding case study is a beneficial pedagogical modality allowing for the building of new information and the expansion of critical thinking similar to real-life situations (Carter & Welch, 2016; Johnson & Flagler, 2013; Yousey, 2013).
Unfolding Case Study
An unfolding case study was developed that incorporates the entire family, centered on a person who becomes addicted to opioids after being in a car accident. The scenario involves an opioid-addicted person along with the ramifications of opioid addiction on the family unit, including both pediatric and geriatric individuals. The unfolding case study includes simulations, activities such as plotting and using growth charts, vignettes, and discussion topics. The scenario begins with all three family members having normal assessments, allowing students to focus on assessment skills and plotting on growth charts at the beginning of the curriculum.
The building blocks of addiction and substance abuse then are provided to prepare students to delve further into the evolving case study. The adult client is involved in a motor vehicle accident that requires surgery for a fractured leg and also results in a back injury. This allows for a simulation of taking care of a postoperative client and providing education for opioid medications. The scenario progresses 6 months, and the adult patient is showing signs of opioid abuse at a follow-up appointment, and his son (the pediatric client) and mother (the geriatric client) are showing signs of possible abuse.
The unfolding case study culminates at the emergency room with an addicted person in septic shock and the family members being abused. Because this unfolding case study was built with a timeline, it is unique in that it can be integrated throughout the entire undergraduate curriculum from assessment to critical care (Table 1). The scenario also has the ability to continue into the graduate program by having the acute care nurse practitioner participate as the health care provider, which allows the benefit of having an interdisciplinary functionality.
Unfolding Case Study Throughout the Undergraduate Curriculum
Third-Semester Undergraduate Curriculum
The comprehensive health assessment course is placed in the third semester of the undergraduate curriculum providing the nursing student with the basic skills needed to perform complete assessments across the life span with a focus on the healthy client. Basic written case study vignettes are used to introduce the three focal characters in the unfolding case study throughout the curriculum. During this course, the vignettes are used to provide healthy persons: a healthy 33-year-old man, a healthy 72-year-old woman who is the adult's mother, and a healthy 4-year-old boy who is the man's child. These three characters are used for nursing students to practice plotting on growth charts and writing assessments of healthy clients; the same three individuals will be used in future semesters to provide a comparison.
Fourth-Semester Undergraduate Curriculum
Promoting Healthy Populations and Pathophysiology-Pharmacology are two courses that occur in the fourth semester of the undergraduate curriculum. Because students need to acquire an understanding of substance use and addiction before proceeding further into the evolving case study, the characters are not incorporated this semester as the nursing students learn the basic building blocks of understanding substance use disorders. In the Pathophysiology-Pharmacology course, the basic information regarding substance use and addictions is discussed; opioids are included but are not the sole focus. The Promoting Healthy Populations course discusses substance use statistics and influencing factors, allowing students to delve into the social aspect of substance use disorders in the local and global community.
Between these two courses, knowledge gained will include physical and chemical changes in the brain from substance abuse, appropriate terms to use, ways individuals start using substances, influencing factors toward addiction, basic assessments to use when speaking with clients about substance abuse (such as screening-brief intervention-referral to treatment [SBIRT]), stigma regarding substance abuse, treatment options, and ways to combat substance abuse. The knowledge gained during this semester is required for use of the evolving case study in the following semesters.
Fifth-Semester Undergraduate Curriculum
One of the course exemplars in the Medical-Surgical 1 course (entitled Clinical Nursing Care 1: Biophysical Processes) during the fifth semester of the undergraduate curriculum is fractures with open reduction and internal fixation (ORIF). A simulation was developed that involved an adult man who is on a medical-surgical floor following ORIF of the tibia and fibula, and back pain after a motor vehicle accident; this patient becomes the central patient in the evolving case study. The patient refuses to get out of bed for meals and frequently requests his pain medication with a preference for the intravenous form over the oral form. The nursing students are expected to perform a complete physical assessment including vital signs and to educate the patient on why it is important to get up into the bedside chair for breakfast. The students also are expected to provide education regarding the importance of ambulation and the benefits of oral pain medications, and they also provide the oral pain medication. Opportunities for discussion will arise during the debriefing session or in the classroom regarding patients being discharged to home with opioid pain medications.
Sixth-Semester Undergraduate Curriculum
The sixth semester of the undergraduate curriculum includes a psychiatric course (entitled Clinical Nursing Care 2: Interactive Processes) and the Medical-Surgical 2 course (entitled Clinical Nursing Care 3: Adaptive Processes). The psychiatric course includes a written case study vignette that featured the adult client in the evolving case study returning to the doctor's office and asking for more pain medication 6 months postoperatively. The vignette contains information about the client exhibiting drug-seeking behaviors, with the prescription-monitoring program showing multiple physicians providing opioid prescriptions.
The students are expected to perform a thorough pain and functional assessment, as well as a substance use assessment screen such as SBIRT, and then report all of their assessment findings to the health care provider. This provides the opportunity for conversations regarding prescription opioid abuse, SBIRT, prescription-monitoring programs, and relaying information to the health care provider. Currently, this vignette also is being worked on to become a simulation to use with the graduate program of the adult-gerontology acute care nurse practitioner program with the expectation for the nurse practitioner to perform a thorough pain and functional assessment, look up the client in the prescription-monitoring system, and provide SBIRT.
Two written case study vignettes regarding the pediatric and geriatric clients were created to be used in the Medical-Surgical 2 course, which covers the life span. Students are provided with the normal assessments and growth charts from the assessment course in the third semester, along with current assessments of both clients in which abnormal findings are present. The geriatric client will have lost weight and have a low body mass index, and the pediatric client will have stalled on growth and regressed in development markers, such as reverted back to bed wetting.
Students are expected to identify the abnormalities in the assessment, plot and compare the growth charts, and note changes; students are expected to surmise failure to thrive in both clients and to assess for the reasons. It is important that the two courses work together during this semester as the timing of the discussions in both courses need to be coordinated, with the psychiatric coursework completed before the medical-surgical course so that the information regarding the adult's drug-seeking behavior is known. Due to its critical nature and prevalence with the opioid epidemic, it is important to note that neonatal abstinence syndrome was included in the maternal-child course during this semester.
Seventh-Semester Undergraduate and Graduate Curriculum
A simulation was created of the adult client in the evolving case study who comes into the emergency department with septic shock due to endocarditis from an infection resulting from heroin injection use. This simulation can be used in the undergraduate Critical Care Course (entitled Clinical Nursing Care 4: Complex Processes) alone during the seventh semester of the undergraduate curriculum, in the Acute Care Nurse Practitioner course with the nurse practitioner functioning as the health care provider, or in combination of these two courses as an interdisciplinary simulation.
The simulation begins with the emergency room nurses receiving a male client who appears to be in shock. The client has track marks on his arms and a decreased level of consciousness. After laboratory tests, diagnostic tests, and a history from the client's mother who is present (the geriatric client in the evolving case study), it is confirmed that the patient is in septic shock due to endocarditis from an infection caused by heroin injection use.
To ensure students looked at the social aspect of opioid abuse while immersed in the acute phase of care, the client's mother had a large bruise on her arm and asked for money to get home because her young grandchild (the pediatric client in the evolving case study) was left alone at home. Students are expected to complete the assessment of the client, follow orders of getting blood for the laboratory work and intravenous, handle any airway needs, help interpret the laboratory results, recognize the abuse of the client's family, and help the family.
The Critical Care Course often does simulation with an interdisciplinary team including physicians or nurse practitioners along with other disciplines, thus an intubation can be added with the students assisting with this task. This simulation contains a rich variety of discussion topics for the debriefing, including the progression of oral opioid abuse to heroin abuse, recognizing sepsis and shock, looking at social aspects of a situation, recognizing abuse during an acute incident, and using resources to get help. The simulation also is a culmination of many concepts taught in the Critical Care Course, such as sepsis, shock, intubation, and ventilator management.
This evolving case study was incorporated into an elective advanced assessment course. However, the simulations were converted to written case study vignettes as this course did not have simulation time built in. Use of the characters across time was beneficial in the course as it allowed for comparisons between assessments. Rich discussions were possible because of the wide array of topics brought up in the evolving case study. Two courses, Pathophysiology-Pharmacology and Health Populations, have incorporated the background information into the curriculum for several semesters, which has assisted in providing a base for students to increase their knowledge regarding addiction.
The final simulation of the client who arrives at the emergency department in septic shock has been used numerous times with the Adult-Gerontology Acute Care Nurse Practitioner Acutely Ill 3 course. The results of the simulations and debriefings increased awareness of substance use and the ramifications on the family. Nurse practitioners were able to provide the acute care for the client including intubation; however, the social aspect of the effects on the family was not noticed by all of the students who completed the simulation. Fortunately, the simulated geriatric client was able to provide repeated cues to the nurse practitioners regarding the need to get home to her young grandson who was home alone, not having money, and being sure the bruising was obvious.
Several of the nurse practitioner groups did notice the social indications regarding the possible abuse and neglect of the geriatric and pediatric clients. A variety of possibilities were suggested to work with the social issues and included asking a nurse to attend to the family, calling a social worker, or calling a victim advocate. The simulation provided rich conversation in the debriefing regarding both the social and acute care sides to the opioid problem. This simulation is being considered for use as a comprehensive final examination for this final course of the Acute Care Nurse Practitioner tract. The evolving case study will continue to be included in the curriculum to provide much-needed opioid education.
- Blozen, B.B. (2013). Prescription opioids: A growing epidemic of abuse. Retrieved from https://www.americannursetoday.com/prescription-opioids-a-growing-epidemic-of-abuse/
- Carter, J.T. & Welch, S. (2016). The effectiveness of unfolding case studies on ADN nursing students' level of knowledge and critical thinking skills. Teaching and Learning in Nursing, 11, 143–146 doi:10.1016/j.teln.2016.05.004 [CrossRef]
- Centers for Disease Control and Prevention. (2019). Opioid data analysis and resources. Retrieved from https://www.cdc.gov/drugoverdose/data/analysis.html
- Hedegaard, H., Warner, M. & Minino, A. (2017). Drug overdose deaths in the United States, 1999–2015. Retrieved from: https://www.cdc.gov/nchs/data/databriefs/db273_table.pdf#1
- Johnson, G. & Flagler, S. (2013). Web-based unfolding cases: a strategy to enhance and evaluate clinical reasoning skills. Journal of Nursing Education, 52(10), 589–592. doi. doi:10.3928/01484834-20130919-02 [CrossRef]
- Lipari, R.N. & Van Horn, S.L. (2017). Children living with parents who have a substance use disorder. https://www.samhsa.gov/data/sites/default/files/report_3223/ShortReport-3223.pdf
- Luke, C., Redekop, F. & Jones, L.K. (2018). Addiction, stress, and relational disorder: A neuro-informed approach to intervention. Journal of Mental Health Counseling, 40(2), 172–186. doi:10.17744/mehc.40.2.06 [CrossRef]
- MentalHelp.net. (n.d.). The diagnostic criteria for substance use disorders (addiction). Retrieved from https://www.mentalhelp.net/addiction/diagnostic-criteria/
- National League for Nursing. (2020). Unfolding cases: Advancing Care Excellence for Seniors (ACES). Retrieved from http://www.nln.org/professional-development-programs/teaching-resources/ace-s/unfolding-cases
- Rappleye, H., McHugh, R. & Farrow, R. (2017). Born addicted: The number of opioid addicted babies is soaring. Retrieved from https://www.nbcnews.com/storyline/americas-heroin-epidemic/born-addicted-number-opioid-addicted-babies-soaring-n806346
- U.S. Department of Health & Human Services. (2017). Determination that a public health emergency exists. Retrieved from https://www.phe.gov/emergency/news/healthactions/phe/Pages/opioids.aspx
- Yousey, Y.K. (2013). The use of unfolding case studies: Innovation online undergraduate nursing education. Journal of Nursing Education & Practice, 3(4), 21–29. doi:10.5430/jnep.v3n4p21 [CrossRef]
Unfolding Case Study Throughout the Undergraduate Curriculum
|Semester||Course Name||Modality Provided||Outcome Expected|
|Third||Comprehensive Health Assessment||Written vignettes||Normal pediatric, adult, and geriatric assessments; plotting on growth charts|
|Fourth||Promoting Healthy Populations; Pathophysiology-Pharmacology||Basic facts||Understanding physical and chemical changes in the brain from substance abuse; appropriate terms to use; ways people start using substances; influencing factors toward addiction; basic assessments and screening to use when speaking with clients about substance abuse; stigma regarding substance abuse; treatment options; and ways to combat substance abuse|
|Fifth||Clinical Nursing Care 1: Biophysical Processes (Medical-Surgical 1)||Simulation||Complete a head-to-toe assessment including vital signs; educate clients on why it is important to get up into the bedside chair for breakfast; provide education on the importance of ambulation and the benefits of oral pain medications; provide oral pain medication; discuss client's discharge with oral opioid pain medications|
|Sixth||Clinical Nursing Care 2: Interactive Processes (Psychiatric)||Written vignette||Perform a thorough pain and functional assessment along with a substance use assessment screen such as SBIRT; report all assessment information to the health care provider; discuss prescription opioid abuse, SBIRT, and prescription monitoring programs|
|Clinical Nursing Care 3: Adaptive Processes (Medical-Surgical 2)||Written vignettes||Identify abnormalities in the assessment; plot on growth charts; compare growth charts and note changes; surmise failure to thrive; assess for reasons for failure to thrive|
|Seventh||Clinical Nursing Care 4: Complex Processes (Critical Care)||Simulation||Complete assessment of the client; follow orders to get blood for laboratory values and intravenous; handle any airway needs; help with interpretation of laboratory results; recognizethe abuse of the client's family; and help the family|