Advanced practice providers take the lead.
- Advanced practice provider-led educational interventions are effective in increasing nursing knowledge.
- Increasing nursing knowledge of naloxone, opioid use disorder, and how to obtain naloxone kits offers a crucial step in improving patient access and improving health outcomes.
- As the opioid epidemic continues, nursing education will prove critical to combating stigma and improving patient outcomes.
Learning Objectives
- Describe the role of naloxone as an evidence-based harm reduction strategy and identify its classification and mechanism of action.
- Identify common barriers to naloxone use and strategies to increase access and referral for treatment of opioid use disorder.
- Explain the impact of naloxone education and training on healthcare providers’ knowledge, attitudes, and interprofessional collaboration.
No relevant financial relationships were identified for any individuals with the ability to control content of the activity.
Expiration: 8/1/28
In 2021, 4 years after the U.S. Department of Health and Human Services declared the opioid crisis a public health emergency, the Centers for Disease Control and Prevention reported that over 75% of overdose deaths in the United States involved an opioid, with nearly 88% involving a synthetic opioid. The use of naloxone to reverse opioid overdose decreases mortality and increases the potential for referral to substance use disorder treatment. However, despite the demonstrated efficacy of naloxone, significant barriers to its use exist, including stigma, access, and lack of education.
To better understand and address these barriers, a cohort of advanced practice providers (APPs) conducted a quality improvement (QI) project at a large urban safety-net hospital.
The problem
The Support Hospital Opioid Use Disorder Treatment (SHOUT) team, composed of APPs and physicians, educates nurses and providers across the network in all general and specialty departments regarding evidence-based treatment of opioid use disorder. In early 2023, the SHOUT team collaborated with frontline team members as well as pharmacy and nursing executive leadership to create a structured process for distributing grant-provided intranasal naloxone kits at no cost to patients with opioid use disorder admitted to medical and psychiatric units. After formal implementation of this process, the SHOUT team identified staff knowledge deficits regarding the use of intranasal naloxone and the process for providing kits to at-risk patients.
Available knowledge
Healthcare workers treat an increasing number of patients with opioid use disorder. Horner and colleagues highlighted the need for educational programs for nurses, who spend the most time with patients, to support quality care of those with opioid use disorder.
APPs and education
Nurse practitioners and physician assistants (master’s-level prepared providers collectively referred to as APPs) rank high among the fastest-growing segments of healthcare workers. Literature regarding education provided by APPs to nurses remains limited, but previous studies have identified APPs’ role in patient education. For example, Kurtzman and Barnow found that nurse practitioners were more likely to provide smoking cessation and health education than physicians. In addition, Ritsema and colleagues found that both physician assistants and nurse practitioners were more likely than physicians to provide health education to patients with chronic health conditions.
Naloxone
Naloxone, an opioid antagonist used as an opioid-reversal agent, is well-established as an evidence-based harm reduction measure. Community and nation-wide efforts strive to improve communication, access, and knowledge about naloxone use among first responders and citizens. In 2023, naloxone was made accessible over the counter to increase nation-wide access. Previous studies, including by Razaghizad and colleagues, found that overdose education and naloxone distribution increase knowledge regarding opioid overdose, improve attitudes toward naloxone, and reduce opioid-related mortality.
The rationale
Literature supports the implementation of naloxone training to increase healthcare workers’ knowledge of opioid overdose treatment. For example, Riley and colleagues found that naloxone administration training to nursing, physician assistant, and pharmacy students increased knowledge as well as confidence and interprofessional teamwork. They recommended adapting this training for other healthcare professionals to improve outcomes in patients with suspected opioid overdose. Hargraves and colleagues found that naloxone training for primary care providers not only improved attitudes but also enhanced knowledge and self-efficacy.
Given nurses’ patient education role, APPs’ demonstrated ability to provide healthcare education, and naloxone education and distribution as an evidence-based intervention, the QI project aimed to determine whether APP-led naloxone education would increase nurses’ general naloxone knowledge, aid availability of naloxone kits, and support harm reduction measures.
The intervention
The hospital network partners with a multispecialty provider group, which includes several post-graduate APP training programs, including a psychiatry fellowship. The fellows must participate in a QI project before graduation. The 2022–2023 fellow cohort (two nurse practitioners and two physician assistants) decided to expand upon a previous QI project regarding naloxone training for nurses.
Based on available information from prior similar studies, the QI team chose pre- and post-surveys (consisting of the same 11 multiple choice questions) to discern the intervention’s impact on nurses’ knowledge. In addition, they developed a presentation to educate participants about opioid use disorder, naloxone, and the process for obtaining a naloxone kit for at-risk patients. An interdisciplinary team that included SHOUT, the fellowship program director, pharmacy leadership, and nursing administration reviewed and endorsed the survey and presentation.
Surveys and presentation
The QI team administered the pre-survey, presentation, and post-survey during the network’s nursing grand rounds via a virtual platform offered free to participants. Nurses received continuing education credit for participating. In addition to the APP fellows, the fellowship program director and SHOUT clinical champion (both experienced behavioral health APPs) participated in the presentation.
After completing the pre-survey, participants watched the 30-minute presentation, which covered the diagnosis, symptoms, and complications of opioid use disorder; indications and use of naloxone; and how to obtain a kit for inpatient and at-risk patients. Participants then completed the post-survey.
Participants consisted of nurses from different specialty units. A total of 91 pre-surveys were submitted before the presentation and 73 post-surveys after.
Measures and analysis
The QI team individually scored the pre- and post-surveys to find the totality of correct responses. This approach allowed them to identify specific knowledge deficits regarding opioid use disorder, naloxone indications, and organizational access to naloxone within the participant group. The team used the pre-survey data to identify areas of opportunity and focus for subsequent presentations, and they analyzed changes in the post-survey to determine which concepts they taught well.
Ethical considerations
The network’s office of clinical research approved this QI project. To maintain participants’ privacy, the surveys were anonymous and individual test scores weren’t linked to any identifiable information. Individual test scores weren’t published or released, and leadership and participants didn’t have access to them.
A total of 91 participants submitted surveys before the presentation and 73 after. The QI team excluded two pre-surveys (one with unanswered questions and the other timestamped after conclusion of the presentation) for a total of 89.
Results
All 11 survey questions showed an increase in score from pre- to post-survey. Six of the survey questions (related to the number of doses in a naloxone intranasal kit, route of administration, when to activate emergency medical services [EMS] in the event of an overdose, how soon to administer a second dose, whether to prime intranasal naloxone, and how to provide kits to patients) showed a statistically significant improvement. The question about activating EMS had the largest increase, but it still had the lowest percentage answered correctly in the post-survey (48%).
Answers to questions about naloxone indications, patient positioning in a suspected opioid overdose, family education, stigma, and harm reduction showed increases in correct answers, but they weren’t statistically significant. Four out of the five questions without statistically significant improvement had a pre-survey score of >70%. The question regarding harm reduction had a pre-survey score of 65%, with an increase to 74%.
The total pre-survey mean score was 63.64% compared to the post-survey mean score of 81.82%. Overall, the team found a significant increase between the pre- and post-survey questions, demonstrating an increase in nursing knowledge. One participant answered all pre-survey questions correctly compared to 13 participants (18%) in the post-survey. A Mann-Whitney U test revealed a significant difference in the number of questions answered correctly from the pre- to post-survey (p-value <.0001). (See Intervention results.)
Outcomes and limitations
This intervention satisfied the project’s aims and demonstrated an overall increase in nursing knowledge of naloxone, opioid use disorder, and naloxone kit access. As anticipated, the findings align with prior studies demonstrating that naloxone education improves naloxone knowledge and that APPs can effectively enhance nurses’ understanding of naloxone. This newfound knowledge equips nurses to identify at-risk individuals and offer interventions.
The pre-survey asked participants to include their department and specialty with the intent to analyze this data. Of the 89 participants who completed the pre-survey, 28 (31%) didn’t include their department and 19 (21%) identified themselves as “other” (which means they may not be RNs). Due to selective participation, the QI team had difficulty assessing significant differences based on specialty and further analyzing this data.
In addition, the team couldn’t link pre- and post-survey data due to protection of the participants’ privacy. This limited the ability to assess the correlation between individual participants’ pre- and post-survey scores. Because the intervention occurred only once, it didn’t capture most of the organization’s nurses.
Combat stigma, improve outcomes
The APP-led educational intervention demonstrated enhanced nurse knowledge of naloxone, opioid use disorder, and how to obtain naloxone kits for patients. The increase of this practical knowledge serves as a critical step in increasing patient access to naloxone and improving health outcomes. Additionally, a better-educated nursing workforce stands poised to identify patients with opioid use disorder and intervene appropriately.
As the opioid epidemic continues, nursing education will prove critical to combatting stigma and improving outcomes. Suggested next steps include examining whether increased nurse knowledge of opioid use disorder and naloxone correlates with increased patient access.
Kathryn Farishta is a psychiatric mental health nurse practitioner at Acclaim Health, JPS Health Network Physician Group in Fort Worth, Texas. A’Vonte Jones is a behavioral health physician assistant at Acclaim Health, JPS Health Network Physician Group. China Santamaria is a psychiatric nurse practitioner at Acclaim Health, JPS Health Network Physician Group. Diana Alvarado is a physician assistant at Franklin Clinic in Kerrville, Texas. Julie Durand is the program director for the Community Psychiatry Fellowship for Advanced Practice Providers at Acclaim Health, JPS Health Network Physician Group. Dustin S. DeMoss is vice chair of education at Acclaim Health, JPS Health Network Physician Group. Amairany Escamilla Meza is a behavioral health physician assistant at Acclaim Health, JPS Health Network Physician Group. Kari Teigen is a biostatistician at JPS Health Network.
American Nurse Journal. 2025; 20(8). Doi: 10.51256/ANJ082506
References
Beauchamp GA, Cuadrado HM, Campbell S, et al. A study on the efficacy of a naloxone training program. Cureus. 2021;13(11):19831. doi:10.7759/cureus.19831
Centers for Disease Control and Prevention. Overdose prevention. cdc.gov/overdose-prevention/?CDC_AAref_Val=https://www.cdc.gov/opioids/basics/index.html
Hargraves D, White CC, Mauger MR, et al. Evaluation of an interprofessional naloxone didactic and skills session with medical residents and physician assistant learners. Pharmacy Pract. 2019;17(3):1591. doi:10.18549/PharmPract.2019.3.1591
Horner G, Daddona J, Burke DJ, Cullinane J, Skeer M, Wurcel AG. “You’re kind of at war with yourself as a nurse”: Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder. PloS One. 2019;14(10):e0224335 doi:10.1371/journal.pone.0224335
Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers. Med Care. 2017;55(6):615-22. doi:10.1097/MLR.0000000000000689
PR Newswire. Advanced practice provider compensation programs shifting to address growing market demand and changing models of care. bit.ly/4kgvLBl
Razaghizad A, Windle SB, Filion KB, et al. The effect of overdose education and naloxone distribution: An umbrella review of systematic reviews. Am J Public Health. 2021;111(8):e1-12. doi:10.2105/AJPH.2021.306306
Riley E, Trotter S, Dayer L, et al. Interprofessional naloxone student training to manage suspected opioid overdose. Clinical Nurse Spec. 2023;37(1):26-35. doi:10.1097/NUR.0000000000000720
Ritsema TS, Bingenheimer JB, Scholting P, Cawley JF. Differences in the delivery of health education to patients with chronic disease by provider type, 2005–2009. Prev Chronic Dis. 2014;11:E33. doi:10.5888/pcd11.130175
U.S. Department of Health and Human Services. Opioids facts and statistics. December 16, 2022. hhs.gov/opioids/statistics/index.html
Keywords: naloxone, opioid use disorder, overdose reversal
