Addressing issues related to addictive behaviors and diagnoses
Nurses should consider innovative approaches to address the complex issues surrounding opioid use during pregnancy. Women often experience barriers to seeking substance use treatment and prenatal care during pregnancy (Howard, 2015; Kramlich et al., 2018). Telehealth may present a solution to meeting the demands for health promotion surrounding the complexity of opioid use disorder (OUD) in pregnancy. Telehealth has the ability to improve communication and collaboration among nurses and other health care providers, expand access to care, and engage patients who may be resistant or reluctant to traditional health care settings (Thompson et al., 2020). Telehealth services for pregnant women with and without OUD have been shown to be as effective as traditional in-person care (Guille et al., 2020; Pflugeisen et al., 2016).
Nursing theory explains and guides patient experiences surrounding health and illness and should be considered when expanding telehealth services (Riegel et al., 2019). A useful theory supporting a telehealth approach to improving the health and well-being of pregnant women with OUD is Imogene King's Theory of Goal Attainment (TGA). Central to TGA (King, 1981) is the significance of nurse–client interaction in setting mutual goals and reaching goal attainment. A gap in the literature exists in using a theory-based approach to the health promotion of pregnant women with OUD using telehealth technologies. Therefore, the purpose of the current article is to inform practice through the design of an innovative, nurse-led approach derived from TGA to care for pregnant women with OUD using telehealth technologies.
The demand for innovative approaches to address the health and well-being of pregnant women with OUD and their infants is increasing as the result of the current opioid crisis in the United States, with rural areas more severely affected (Kozhimannil et al., 2020; Patrick et al., 2019). In a recent national survey, 5.4% of pregnant women used illicit substances with 0.9% of pregnant women reporting opioid use (U.S. Department of Health and Human Services, 2019). Rates of maternal opioid use have risen dramatically and increased from 1.5 cases per 1,000 hospital births to 6.5 cases per 1,000 hospital births between 1999 and 2014 (Haight et al., 2018).
Opioid use during pregnancy can result in a variety of complications, including oral clefts, ventricular septal defects, atrial defects, low infant birth weights, and respiratory problems (Bordelon et al., 2020; Forray, 2016; Lind et al., 2017). Many infants will experience neonatal abstinence syndrome (NAS) as the result of prenatal opioid exposure. NAS, a withdrawal syndrome, includes many symptoms, such as irritability, hyperreflexia, poor feeding, tremors, sweating, sneezing, and yawning (Reddy et al., 2017). Infants with NAS tend to have increased length of hospital stays and are more likely to be transferred to another hospital (Winkelman et al., 2018). Rates of NAS incidence increased more than five-fold from 2.8 per 1,000 births to 14.4 per 1,000 births between 2004 and 2014 (Winkelman et al., 2018). Total hospital costs for NAS covered by Medicaid increased from $65.4 million to $462 million during the same time period (Winkelman et al., 2018).
In addition to prenatal care, access to substance use treatment during pregnancy is critical to improving the health and well-being of pregnant women with OUD and that of their infants. Substance use treatment during pregnancy promotes better birth outcomes and has shown lower rates of prematurity and low birth weight infants (Kotelchuck et al., 2017). Medication-assisted treatment (MAT) with either methadone or buprenorphine is considered the preferred treatment for OUD during pregnancy. MAT prevents opioid withdrawal symptoms, prevents relapse, and improves adherence to prenatal care and substance use treatment (American College of Obstetricians and Gynecologists [ACOG], 2017). The ACOG (2017) recommends that health care providers identify and refer women using substances to addiction treatment professionals. However, barriers to substance use treatment with MAT and prenatal care exist for pregnant women and include stigma and fear of loss of infant custody (Howard, 2015; Kramlich et al., 2018; Renbarger et al., 2020). Lack of access to treatment is another contributing factor to low use of MAT, particularly in rural areas of the country (Jones et al., 2015; Kramlich et al., 2018). Often-times, women must seek MAT providers who are in separate facilities from their prenatal providers. Some women who use substances during pregnancy have reported problems with availability of treatment, getting to and from appointments, and coordination among providers (Kramlich et al., 2018). The Guttmacher Institute (2020) reports that only 19 states have substance use treatment programs specifically targeted to pregnant women, with as few as 17 states offering pregnant women priority access to state-funded treatment programs. Only 10 states prohibit publicly funded substance use treatment programs from discriminating against pregnant women.
Moreover, treatment of OUD in pregnancy is complex and a variety of comprehensive services are needed. The Substance Abuse and Mental Health Services Administration (SAMHSA; 2016) reported that pregnant women with OUD often present with complex histories that include sexual abuse, interpersonal violence, inadequate social supports, unpredictable parenting models, poor nutrition, unstable housing, and co-occurring psychiatric conditions. According to Reddy et al. (2017), pregnant women with OUD may need specific treatment services that include prenatal counseling regarding risks of opioid use, comorbid conditions screening, liver function tests, electrocardiogram prior to starting methadone, psychosocial care, and obstetrician–gynecologist prenatal care. Nurses who provide maternity care in outpatient settings, including prenatal clinics and homecare, play a key role in the development and delivery of tailored treatment services to address the complex issues of pregnant women with OUD that may hinder their overall health and wellness.
Telehealth services are emerging and evolving across the lifespan and health continuum to expand access to care. Reimbursement for telehealth services varies by state, and nurses often provide care in conjunction with a qualified provider (Center for Connected Health Policy, 2020). Currently, the Centers for Medicare & Medicaid Services (CMS; 2020a) has expanded to increase access to and provisions of care for telehealth. Criteria for most of the reimbursement requirements have been waived since the declaration of the current public health emergency and have established 1135 waivers (CMS, 2020a). These waivers allow for modifications to or the waiving of Medicare, Medicaid, or Children's Health Insurance Program requirements during an emergency to increase access to health care (CMS, 2020a) The 1135 waivers will ensure continuity of care and expand access by including technical devices for pregnant women with OUD. More pregnant women with OUD may also be eligible to receive telehealth services through the expansion of reimbursable services through Medicaid. States can decide to cover telehealth services under Medicaid and are encouraged to use the flexibility to create innovative payment methods for services that incorporate telemedicine technology (CDC, 2020). By expanding access to cost-effective care, telehealth can promote positive health outcomes by reducing barriers faced by pregnant women with OUD to receiving peri-natal care and substance use treatment (Guille et al., 2020). Telehealth services can be used to provide supportive health care services to communicate a diagnosis, provide health promotion education, provide follow up with clients who missed clinic appointments, decrease wait times, assess the home environment, and evaluate follow-up care (Gately et al., 2020; Kruse et al., 2017). The modalities include video conferencing, mobile health, and remote patient monitoring. Service delivery can be synchronous (real-time) or asynchronous (store and forward). Text messaging can be used for appointment reminders and motivational messaging (Mayer & Fontelo, 2017; Saberi, 2020). Video conferencing can be used with interventions that do not require a physical presence but provide face-to-face communication, such as for mental health services and health promotion counseling (Mayer & Fontelo, 2017).
Limitations of telehealth include lack of access to technical devices, ethical concerns, licensing, patient privacy, and the security of information (Fathi et al., 2017). Efforts should be made to reach more patients with limited technology access by offering flexibility in telehealth platforms, such as the use of non-video options (CDC, 2020). Other limitations of telehealth services include safety concerns that may arise during telehealth sessions. Many safety concerns could be mitigated with policies and procedures in place and working with on-site staff to address issues, such as general emergencies, behavioral health concerns, self-harm, and interpersonal violence (CMS, 2020b).
Although telehealth services cannot replace all in-person visits that require physical and urine drug screenings, pregnant women with OUD can benefit from a wide range of perinatal telehealth services. Telehealth services during pregnancy include at-home monitoring for conditions, such as diabetes and hypertension, and for consultations with specialists, such as high-risk obstetricians, lactation consultants, and mental health care providers (Weigel et al., 2020). Telelactation has been shown to be an effective way to provide professional breastfeeding support to a rural population of women (Kapinos et al., 2019). Considering rates of NAS have occurred disproportionately in rural and impoverished communities, telehealth technologies may be a significant strategy to increase substance use treatment access and improve NAS health outcomes (Guille et al., 2020; Patrick et al., 2019).
TGA, a middle range theory, is derived from an open systems framework based on mutual perceptions in the nurse–client relationship and effective communication, which are among the necessary requirements of nursing practice. Nurses can better understand clients' conditions, enhance care quality, and improve quality of life through effective nurse–client relationships (Adib-Hajbaghery & Tahmouresi, 2018). King's (1981) conceptual framework is based on the nursing process and has three dynamic interacting systems that contain concepts that are interrelated and influence communication and behaviors of nurse–client interactions for goal setting and goal attainment:
Personal (individual) comprises perception of self, body image, growth and development, time, space, and learning.
Interpersonal (group) encompasses interaction, communication, transaction, role, stress, and coping.
Social (society) includes organization, authority, power, control, status, and decision making.
The nurse–client interaction and effective care are key to implementing TGA (King, 1981). Perception is a major concept for nurses to develop as it influences behavior of the person and is the first step for mutual goal setting (King, 1981). Interpersonal concepts include personal and social interactions to form dyads, triads, and small groups using verbal and nonverbal communication. Significant development of TGA was attributed to the interpersonal system where the nursing process occurs (Adib-Hajbaghery & Tahmouresi, 2018). The proposed practice model using telehealth technologies adheres to four basic propositions of TGA, which include (a) nurse and client need to have a mutual understanding of each and assess perceptions of the other; (b) goals are attained through the nurse–client interaction; (c) role expectation and performance must be congruent through mutual goal setting and decision making; and (d) nurses must use their knowledge and skills to assist clients in achieving their goals (Adib-Hajbaghery & Tahmouresi, 2018; Theriot, 2016).
Assessment of Perceptions
It is essential for nurses using telehealth technology to be cognizant of their perceptions, specifically for assisting, interpreting, and elaborating the therapeutic plan with pregnant women with OUD. Both individuals perceive the other and make certain judgments, which influence the nurse–client relationship (King, 1981). King (1981) defined perceptions as each person's representation of reality, which includes an awareness of persons, objects, and events as well as each person's subjective world of experiences. Assessing perceptions involves relating to past experiences, self-concept, values, socioeconomics, biological effects, and one's education (King, 1981).
In the nurse–client interaction with pregnant women with OUD, perceptual accuracy is essential to the development of a positive health care experience. Erroneous perceptions have the potential to lead to inappropriate judgments and impair the ability of the nurse to work toward mutual goal setting and attainment. For example, women who use substances during pregnancy have reported feeling judged by nurses and other health care providers and as a result did not trust providers to protect them and avoided seeking care (Harvey et al., 2015; Renbarger et al., 2020). Women who used substances during pregnancy have also perceived that health care providers questioned their ability to be a mother in the post-partum period (Harvey et al., 2015; Renbarger et al., 2020). Women want to be seen as the mother of the infant and to be involved in the infant's care (Harvey et al., 2015; Renbarger et al., 2020). Nurses need to be aware that women who use opioids and other substances are more likely to have positive experiences with health care providers who they perceive as accepting rather than judging them for their substance use (Renbarger et al., 2020).
Telehealth may then be a useful tool to overcome perceptual barriers and improve nurse–client interactions with pregnant women with OUD. Clients perceived the use of telehealth as being less intimidating than an in-office health care visit and, therefore, were less nervous and more open to sharing their feelings and other sensitive information (Saberi, 2020; Saberi et al., 2013; Slightam et al., 2020). Clients with mental health and substance use issues preferred telehealth services to avoid the chance of running into acquaintances or community members in clinic waiting areas (Saberi et al., 2020). By reducing perceptions of being judged or stigmatized, telehealth services may promote health and wellness and provide perceptions of a less intimidating environment for which nurse–client interactions could occur.
Communication in the Nurse–Client Interaction
According to King's theory (1981), mutual goal setting and goal attainment can occur when nurses are able to effectively communicate and give appropriate information to clients. The goal is attained through purposeful activity of individuals and groups performing as open systems in the transaction of energy through communication. King (1981) acknowledged that the goal of nursing is to help patients attain, maintain, and restore health, in which communication is an effective means to goal attainment.
The need for supportive communication exists between nurses and pregnant women with OUD because of stigmatizing and adverse experiences with health care providers (Demirci et al., 2015; Howard, 2016; Renbarger et al., 2020). Women with OUD have reported that health care providers did not listen to them, minimized their feelings, and felt providers were unsupportive (Demirci et al., 2015; Renbarger et al., 2020). Sometimes, difficulty between health care providers and women who use opioids and other substances during pregnancy occurred as the result of stigmatizing language. The use of terms such as “addict,” “substance abuser,” and “opioid addict” for the person and “clean” and “dirty” to describe toxicology screens are associated with negative perceptions (Ashford et al., 2018; Office of National Drug Control Policy, 2017; Renbarger et al., 2020). The use of stigmatizing language may negatively alter self-perceptions of pregnant women with OUD resulting in lower self-esteem and decreased feelings of empowerment (Ashford et al., 2018).
Telehealth can improve communication by improving access to health care and substance use treatment providers who are knowledgeable about the issues surrounding addiction (Jackman et al., 2019; Kruse et al., 2017). Nurses who are proficient in communication can use their skills through telehealth as an intervention to assist pregnant women with OUD in reaching goal attainment. Motivational interviewing, a therapeutic communication intervention designed to enhance client readiness to change health behaviors, has been found to be effective in reducing the use of substances (Frost et al., 2018). Using motivational interviewing through telehealth services, trained nurses can guide pregnant women with OUD to identify problems and make decisions. A systematic review by Shingleton and Palfai (2016) demonstrated that technology-delivered adaptations of motivational interviewing for health-related behaviors are practical to implement and well-accepted.
Mutual Goal Setting and Decision Making
According to King (1981), mutual goal setting should occur in every nursing encounter and involves the joint creation of the methods to achieve the goal. Nursing involves recognizing a presenting condition, managing activities related to the situation or condition, and motivating to exercise some control over the events in the situation to achieve goals (King, 1981). When the ability to accomplish the goal has been explored, nurses and clients can move together toward goal attainment (King, 1981). The success of the nurse–client dyad depends on the expertise and skills of the nurse to help guide clients in accomplishing goals. The client's willingness to engage equally in goal setting and decision making is just as important to goal attainment as the expertise of the nurse (Caceres, 2015). King (1981) believed that clients have the right to participate in decisions that influence their health. Nurses have a unique responsibility to share information that assists clients to make informed decisions about their health and well-being. Nurses gather important information regarding the perceptions of the client so that goals of the nurse and client are congruent (King, 1981).
To set mutual goals as described by King (1981), nurses must take care to include pregnant women with OUD in decisions about care of themselves and that of their infant after birth. By empowering self-management, women are allowed to experience co-responsibility in the management of their health and well-being. Oftentimes, pregnant women who use substances sometimes believe health care providers do not include them in decisions about their own care or that of their infants, which could alter their motivation to participate in their health care (Demirci et al., 2015; Howard, 2015; Renbarger et al., 2020). Therefore, nurses working with pregnant women with OUD need to negotiate priorities, motivate sharing and participation, and encourage women to participate in the management of their own health and that of their infant during the pregnancy and after birth. Nurses must assess women's values during their pregnancy and their anticipated outcomes of their infants to establish mutual and congruent goals.
Telehealth services based on King's (1981) model could benefit pregnant women with OUD by connecting them to various providers who have specialized knowledge in treating women with OUD and understand the complex issues surrounding addiction. For example, breastfeeding has been shown to have the benefits of reducing the symptoms and severity of NAS (Wu & Carre, 2018). However, women do not always feel supported in the choice to breastfeed when prescribed MAT for their substance use (Demirci et al., 2015). Using telehealth services could expand women's opportunities to consult with lactation consultants who are knowledgeable and supportive in regard to breastfeeding while taking MAT.
In addition, some women have difficulties in having substance use providers and prenatal providers in two different facilities (Kramlich et al., 2018). Telehealth services could be used to coordinate substance use treatment and prenatal care and provide up-to-date health information allowing women to actively participate in their own care. Currently, telehealth use for OUD in pregnancy has shown promising results, with findings of a recent study indicating that outcomes such as retention in treatment, NAS symptoms, positive drug screen results, and newborn days in the hospital after delivery were similar to outcomes of standard in-person care (Guille et al., 2020).
Health Promotion and Goal Attainment
Using King's (1981) theory to guide a practice model using telehealth, nurses use their knowledge and skills to assist clients in health promotion and goal attainment. Pregnancy is an opportune time for nurses and other health care providers to improve the health and well-being of women with OUD. Telehealth services reduce barriers to treatment and assist nurses in providing care to women with OUD during pregnancy. Nurses could use telehealth to provide necessary services such as screening for substance use, screening for comorbidities and other mental health disorders, providing referrals to specialists, providing contraception and sexually transmitted infection education, and delivering breastfeeding counseling. Referrals to social service providers could be made to address issues such as homelessness, prostitution, safe housing, sexual violence, and other trauma that women may be experiencing (Krans et al., 2015; Reddy et al., 2017).
Telehealth could also be used to assist a pregnant woman with OUD to develop a safe plan of care for an infant with NAS for the transition home (Bordelon et al., 2020). Pregnant women with OUD may be caring for an infant with NAS and will need to be educated on four essential components of a “safe plan of care” agenda that includes responsive caregiving, safe environments, appropriate nutrition, and specific health-promoting care management (Bordelon et al., 2020). Engaging family in the care of an infant with NAS produces positive outcomes, including the enhancement of maternal-infant bonding, decreased complications from NAS, improvement of feeding behaviors, and increased caregiver confidence (Bordelon et al., 2020; Dodds et al., 2019). Early engagement and intervention of health care providers with family caregivers improve outcomes and minimize the risk of women disconnecting from necessary resources they need (Bordelon et al., 2020). A hypothetical case study is provided to allow insight into the use of King's (1981) framework with a pregnant woman with OUD.
A.Y. is a 26-year-old single female who is currently unemployed and 28 weeks pregnant. She is gravida 1 para 0, has a history of OUD for 5 years with a diagnosis of DSM F11.20 Opioid Use Moderate Disorder (APA, 2013). She is prescribed Suboxone® sublingual 4 mg/1 mg daily for treatment stabilization through a MAT provider who is separate from her prenatal office.
A.Y. is scheduled for a follow-up prenatal appointment through video conferencing after missing her in-person appointment at the local obstetric office. At a prior in-person appointment, the client had expressed an interest in breastfeeding her baby.
The nurse explains the telehealth process and purpose of the follow-up visit. The nurse uses motivational interviewing strategies, including empathy, support, and reflective listening, to further assess self-efficacy, coping skills, and readiness of change.
Nurse: “I understand you would like to learn more about breastfeeding your baby.”
Client: “I want to breastfeed my baby, but I am scared because of my medication and worry I might use drugs.”
The nurse encourages the client to talk about the need for change. Nurse: “I am supportive of your goals, what do you wish to change?”
Client: “Being pregnant, I realize the harm the drugs could cause to me, and I don't want that for my baby. I want to stay offdrugs and be able to breastfeed my baby.”
Nurse: “What is your understanding about breastfeeding?”
Client: “I know breastfeeding is good for my baby and will keep my baby healthy, but I don't know if it is safe because I take Suboxone or if I use other drugs.”
Nurse: “Those are wonderful reasons to breastfeed. What are your triggers for substance use?”
Client: “My family is upset with me, my car isn't working, and I am afraid of losing my baby.”
Nurse: “Those are difficult challenges. What changes do you need to make to avoid using substances?”
Client: “I need to stay on my Suboxone, stay away from friends who use drugs, and come to all of my appointments. I want to be a good mom.”
Nurse: “Your baby is very important to you. Based on the information you have shared, we can coordinate scheduled video conferencing sessions in conjunction with your in-person prenatal appointments. We can refer you to a lactation consultant who uses telelactation services for education on breastfeeding while taking your prescribed Suboxone to reduce the need of additional office visits.”
The opioid crisis in the United States is indeed staggering and pregnant women with OUD have been dramatically affected by it in the past decade. Many pregnant women with OUD face barriers to substance use treatment and prenatal care, which can promote health and well-being of women and their infant after birth. Telehealth can be a useful means of providing a connection between pregnant women with OUD and nurses. Using theory-driven practice within the encounter with TGA allows for a therapeutic relationship of mutual understanding for better goal attainment. Using King's (1981) theory to guide the development of telehealth strategies to address opioid use during pregnancy, nurses can address perceived stigma, communication barriers, logistical barriers, difficulties in mutual goal setting and decision making, and challenges to health promotion to support pregnant women with OUD in attaining goals for optimal health and well-being.
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