Did you have any specific reasons for applying?
I started in substance misuse about 14 years ago, I got sent on a placement and I loved it. Our clients were the most honest and raw group of clients I have ever met, and it was very refreshing for me coming from mental health services. I felt it covered such a broad range that you never got bored.
There’s all the mental health spectrum and social working, and clients never ever give up, despite getting thrown the worst things in life, and I think that’s something we can all learn from. That’s the reason I’ve applied and the reason I’ve stayed and naturally progressed in my role.
What do you enjoy the most about your work?
Recently I enjoy strategic stuff the most. We have loads of different projects going on at the moment, and that’s what I’m good at. It’s very easy to get burnt out in substance misuse, and at the minute I am enjoying the strategic side―putting pathways in place, trying new processes, reviewing new ways of working and improving things. I love a good audit!
What’s it like leading a team of nurses?
I have been a Lead Nurse for about five years now. The team was huge when I started because we also had non-nurses doing prescribing clinics, so at that point I was supervising about 9 people. My team currently stands at four nurses.
We are a tight team, we’ve worked together for a long time, but being a nurse and a manager can be a hard balancing act sometimes because the cross-over is not always smooth.
What are the biggest challenges in your role? And the biggest rewards?
We’re having an increase in complexity of clients―we’re facing an ageing group of drug users who might have started using in 1980, they are now reaching their mid-40s and they have the body of 80-year-olds and all the complications that go alongside that. It’s a challenge to safely manage this, whilst balancing budgets and staff skills.
Death is unfortunately a big part of this job and you’re at risk of becoming quite immune to it and quite sad, so I think the biggest challenge there is having to be a bit detached.
As for the rewards, I think the biggest ones are what people don’t think of as the glamorous ones.
For me it’s somebody who comes in with a smile on their face, especially if I’m having a bad day, and they’ll have made a bit of progress, or they’ll thank you for the chat you had the previous week, and then you think ‘that’s why I do it’. It’s not the shiny, exciting, big service changes, it’s just the fact that you have made a difference to one person who is otherwise completely alone.
Who do you work with in your role?
Client wise, I always thought drug users were homeless people who had a horrendous upbringing, but actually we work with everybody from that homeless person right up to white-collar workers― anyone who might have happened to just pick up the wrong coping mechanism. With the alcohol clients especially, you realise you are one step away from it, and for many it’s like “how did I get here?”
Colleagues-wise, we work with lots of different agencies. We work a lot with the hospital, hepatology and liaisons nurses, we work with criminal justice, with domestic abuse charities, mental health services, women and homeless services, and the recovery team.
Do you deliver any training?
I do ad-hoc training to other people – for instance teaching somebody to perform an ECG or to take blood and safe injecting. I have delivered lectures to student midwives in a bid to get some compassion and interest in substance misuse in pregnancy. A lot of our women do struggle, as on the one hand you have to be the supportive nurse to a pregnant woman, and on the other hand you might have to write reports to get their child taken away, so it can be very difficult to manage. I take student nurses and student GPs and give them training too.
Which skills do you need to be a substance misuse nurse?
The most important ones are patience and a very good sense of humour. You need to set boundaries, have confidence in your abilities as well as in what you don’t know, which is very underrated. If you are aware of what you don’t know you’re halfway there.
You need to be a jack of all trades and a master of none. You do need a general awareness of the key physical health conditions, the key medications that crop up, certainly an awareness of mental health in trauma, and you need to be a team player – there is no room for lone wolves in substance misuse, it’s about sharing up that role to protect yourself, the clients and others. It’s important not to do things for a client, but instead tell them how to do something and let them do it themselves – that’s how people recover and learn.
As a line manager, you need structure and boundaries. The chaos never stops, you’ll never complete everything you need to do. If I have a management day, I know I should do management stuff otherwise the work piles up. In theory I try and divide my days in management and clinical days, but it does bleed over.
Are there any misconceptions about being a substance misuse nurse?
As a substance misuse nurse, people often raise their eyebrows when you say what you do. The misconception is that you are dealing with less of a human being somehow, getting shouted at and working with people who don’t want to get better. But it’s the complete opposite―everyone wants to get better. The judgement on people can be harsh.
What does a typical day look like for you?
On a clinical day you have a clinic, and then there’s the duty stuff to deal with. A general day is filled with anything and everything that comes through the door. We have a meeting every morning, there’s usually up to 10 people we need to discuss that have some decisions needing. At the moment, with COVID, it’s quite lonely. Now you’re stuck in a clinical room alone a lot of the time and sat down a lot. We can only let through one person at a time, which is also weird.
How did COVID-19 change the way you work?
The main thing that has changed with COVID is how we talk and deliver interventions. The majority is remotely and via the phone. We didn’t use to do phone appointments at all, it was very rare as we used to always see everyone in person. What’s tricky is that most of your assessment is done in the corridor over to your room, in how that person’s body language is like, what they look like, are they under the influence, are they upset etc.., but it’s very hard to get that over the phone. And that affects your confidence in safety. But it’s a double-edged sword because clients answer the phone when they wouldn’t normally turn up, and sometimes it works better for them, because they are more relaxed and happier that they don’t have to come into the clinic.
At the beginning, we gave everyone a week’s worth of medication, and we were terrified at what would happen but actually the majority of our clients used it as an opportunity to stop using and behaved completely responsibly. We used it as a learning point, realising that we don’t want to go back to daily supervision because in the majority of cases people are managing it really well. So, there were some positives to it as well in the way that it forced our hand to take some positive risks.
What range of conditions do you deal with in your role?
I deal with cancer, asthma, diabetes, COPD, circulatory and respiratory conditions.
How many patients do you typically treat in a day?
Up to about 25 that we need to call or see. On top of that, there is a lot of batch prescribing― extending prescriptions and quick spot checks. There’s usually 8 people in a clinic with two clinics a day, and everyone else on top of that. Since COVID we see less people face to face, although the clinic size is the same because we do a lot of calls.
What would you say to someone thinking of applying?
It’s always worth an application, even if you feel you have no experience in this area. Sometimes no experience is more beneficial in substance misuse, because you come into it with enthusiasm and a fresh pair of eyes. Also, clients respond really well to somebody new, like a student, because they enjoy being the expert rather than someone saying the same message over and over. And you can always learn. That’s why I love having student nurses, because they bring a fresh perspective and a willingness to try things, and for me it’s invigorating and a reminder of why I enjoy doing the job.