Substance Abuse by Nurses

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Clinical Journal of Oncology Nursing • Volume 13, Number 1 • Professional Issues 17

JeanAnne Johnson Talbert, APRN-BC, FNP, MSN, AOCN®, DHA, is a chief clinical officer at Mountain View Hospital in Spanish Fork, UT.

Digital Object Identifier: 10.1188/09.CJON.17-19

Substance Abuse Among Nurses

Professional issues Jeananne Johnson TalberT, aPrn-bC, fnP, Msn, aoCn®, Dha—assoCiaTe eDiTor

JeanAnne Johnson Talbert, APRN-BC, FNP, MSN, AOCN®, DHA

Tammy is an excellent clinician. She is fluent in oncology terminology and able to teach patients and colleagues about cancer care. She seemingly is dependable and often picks up extra shifts when the oncology unit is short staffed.

One night, as the nurse comes on shift to relieve Tammy, a patient says her pain is a 10 on a 10-point scale. The nurse is concerned because the medication admin- istration record indicates that the patient has had frequent doses of pain medication as needed. She calls the physician to report the severe pain the patient is experiencing and receives an order to increase opioid pain medication. Shortly after the nurse administers the medication, she checks on the patient to find her unresponsive, with an oxygen saturation of 81% and very slow, shallow respirations. After calling the Rapid Response Team and administering naloxone, the patient arouses, and her oxy- gen saturation increases. When the patient is stabilized, the nurse takes a minute to reflect. What happened to the patient?

The nurse realizes that for the past two months, every time she has followed Tammy on shift, the patients have com- plained of unrelieved pain, even though the medication administration record indicates they were being medicated fre- quently with opioid analgesics. Further- more, her colleagues have complained about Tammy’s decreasing work ethic; Tammy takes longer and more frequent breaks and exhibits irrational behavior.

Does Tammy show signs of impaired nursing? If so, what should the nurse do about it?

Substance Abuse Among Nurses

Drug and alcohol abuse is a serious health and social problem in the United

States. Addiction and dependency affect adolescents and older adults, all ethnici- ties, and all socioeconomic levels. The prevalence of alcohol and drug abuse in the nursing population is believed to parallel that of the general population (Dunn, 2005). Approximately 10% of the nursing population has alcohol or drug abuse problems, and 6% has problems serious enough to interfere with their ability to practice (Ponech, 2000). The American Nurses Association (ANA) esti- mated that 6%–8% of nurses use alcohol or drugs to the extent that professional judgement is impaired (Daprix, 2003).

Impaired nursing practice is defined as a nurse’s inability to perform essential job functions because of chemical de- pendency on drugs or alcohol or mental illness (Blair, 2002). Since the early 1970s, impairment has been studied among the nursing profession and has been linked to several fac- tors. The first factor is family history. Nurses who have a family history of emotional impairment, alcoholism, drug use, or emotional abuse, resulting in low self- esteem, overwork, and overachievement, are at greater risk for using or abusing substances (Monahan, 2003). Being in an environment with dependent family members may lead to enabling behavior, which often is described as “helping” be- havior. People who fit this category may be attracted to the nursing profession because of the opportunity to continue in a caregiving role.

Stress in the workplace is another rea- son cited for nurses abusing substances.

As staffing levels decline, workloads increase, especially with increases in acu- ity among hospitalized patients. Rotating shifts, working overtime, and floating to different departments contribute to stress, fatigue, and feelings of alienation; substance abuse may be a way of coping. Nurses tend to be described as “worka- holics” and may not be able to deal with the stress the work brings (Monahan, 2003).

The availability and accessibility of medications also has been linked to sub- stance abuse among nurses (Serghis, 1999). Nurses are trained that medica- tions solve problems. Every day, nurses administer medications to alleviate pain, combat infections, diminish anxiety and depression, and treat illnesses such as

cancer. Nurses administer medications to assail side effects of other medica- tions. The workplace of a nurse has an intrinsic culture that accepts pharma- cologic agents to cure ailments (Dunn, 2005). Medications are easily accessible to nurses, who may believe erroneously that they have the ability to control their own medication use because of their experience with administering medica- tions to patients. Nurses have the ability to obtain undiverted medications by ask- ing a colleague to write a prescription or by forging a prescription or may obtain

Substance abuse among nurses is a problem that threatens the delivery of quality care and professional standards of nursing.

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18 February 2009 • Volume 13, Number 1 • Clinical Journal of Oncology Nursing

medications through diverted methods such as using medications intended for patients.

Substance abuse among nurses is a problem that threatens the delivery of quality care and professional standards of nursing. Many nurses are not identified as having a problem until patient safety has been compromised (Clark & Farnsworth, 2006). Substance abuse may be a primary problem or a result of treatment for an- other condition, such as depression or back pain. In a study by Trinkoff and Storr

(1998), rates of substance abuse among nurses varied by specialty, even with controlled sociodemographics. Compared with nurses in women’s health, pediatrics, and general practice, emergency nurses were 3.5 times as likely to use marijuana or cocaine (odds ratio [OR] = 3.5; 95% confidence interval [CI]= 1.5, 8.2); oncol- ogy and administration nurses were twice as likely to engage in binge drinking; and psychiatric nurses were most likely to smoke (OR = 2.4; 95% CI = 1.6, 3.8). No specialty differences appeared for prescription-type drug use. Alcohol may serve as a coping mechanism for oncol- ogy nurses to ease the emotional pain as- sociated with working with patients with cancer. Exposure to death and dying also has been linked to substance abuse, which is familiar to oncology nurses (Trinkoff & Storr).

Signs and Symptoms Many signs and symptoms of sub-

stance abuse are general, nonspecific, and easily hidden. However, over time, an individual’s behavior paints a clearer picture. Nurses with substance depen- dency often use before and during their shifts (Ponech, 2000). Signs to watch for include increased absenteeism, frequent disappearances from the department or unit, excessive amounts of time spent in medication rooms or near medication carts, work performance that alternates between high and low productivity, and inattention or poor judgement (Drug

Enforcement Administration [DEA], 2008). Other signs of substance abuse include damaged relationships among colleagues, friends, and patients; heavy “wastage” of drugs; personality changes, such as mood swings, anxiety, depres- sion, and isolation; and increased con- cerns voiced by patients.

In the previous scenario, the assump- tion is that Tammy is taking medication intended for patients for use either during or after shifts. She may be substituting the medications with other substances that

have similar characteristics, such as saline, or she may be giving patients smaller doses than what she documents, while keeping the remaining medication for herself. The decreased pain management among her patients, her in-

creased willingness to pick up extra over- time shifts, and the changes in her work standards and behavior are indicators of a substance abuse problem.

Should the Nurse Become Involved?

Nurses usually avoid dealing with impaired colleagues (DEA, 2008). Of- ten, nurses who work together develop friendships, which can be an obstacle to recognizing and addressing problem- atic behavior or nursing practice (Dunn, 2005). Nursing departments frequently encourage and reinforce teamwork prac- tices, such as helping each other during stressful times, which also can be a bar- rier. A study indicated that nurses may ob- serve unsafe behaviors but are reluctant to report nurses they consider friends (Booth & Carruth, 1998).

In addition, nurses have a tendency not to report other nurses for fear of ret- ribution, creating problems in the work environment, or being labeled as a whis- tle-blower (Dunn, 2005). Cerrato (1988) reported a study in which 91% of nurses who responded to a survey stated they would report an incident that harmed patients or put them at risk for harm; however, only half of the nurses actually reported incidences they had witnessed. Avoiding or denying the problem of sub- stance abuse only puts patients, organi- zations, and the profession of nursing at greater risk. Nurses who have substance abuse problems that are not addressed

are able to work in different organiza- tions and settings, putting themselves and their patients at risk for harm.

Nurses have an ethical and legal ob- ligation to report colleagues who ex- hibit behaviors that could be detrimental to patients (Dunn, 2005). Patients are vulnerable and have the “right to safe, skilled care administered by a nurse who is physically able” to perform his or her duties (Sullivan, 1994, p. 21). ANA stated that nurses are responsible to respond to a colleague’s questionable practice as advocates for patients. Furthermore, nurses are acting as advocates for their colleagues because reporting nurses who abuse substances may save their licenses or even their lives.

Boards of nursing are mandated to protect the public from unsafe nursing practices, and many states have devel- oped treatment programs for impaired nurses rather than taking immediate dis- ciplinary action against nurses’ licenses to practice (National Council of State Boards of Nursing, 2001). In fact, most states have adopted programs that offer nurses treatment and recovery programs, monitor their return to work, and prevent their licenses from being revoked or sus- pended (Clark & Farnsworth, 2006).

The most important intervention the nurse can make is to report Tammy. Most often, this means reporting her to the nurse manager and also may involve noti- fying the State Board of Nursing. Either op- tion is acceptable, and the decision may be influenced by hospital policy, the nurse’s relationship with the nurse manager, or if the nurse feels no action is taken. By no- tifying the manager or the State Board of Nursing, the nurse is advocating for the pa- tients Tammy cares for, her organization, her profession, and her colleague, Tammy. More than 39 states offer programs that provide rehabilitation without punitive interventions. Rehabilitative programs rely on high rates of reporting and self- reporting among nurses (Blair, 2002).

In conclusion, substance abuse among nurses parallels that of the general popu- lation and places patients, the public, organizations, the nursing profession, and nurses in harm’s way. An estimated 6%–8% of nurses in the United States have substance abuse problems severe enough that their ability to practice is compromised. Among specialty nurses, oncology nurses are among the most

Nurses have an ethical and legal obligation to report colleagues who exhibit behaviors

that could be detrimental to patients.

Clinical Journal of Oncology Nursing • Volume 13, Number 1 • Professional Issues 19

frequent substance users because of the stressful demands of the job, the exposure to death and dying, and the accessibility to medications. Nurses are ethically and legally responsible to re- port coworkers who exhibit behaviors of impairment. Nurses must be not only patient advocates but also nurse advo- cates. The characteristic nurses share is a desire to help people, and a colleague may be one of the lives nurses save during their careers.

Author Contact: JeanAnne Johnson Talbert, APRN-BC, FNP, MSN, AOCN®, DHA, can be reached at [email protected] .com, with copy to editor at [email protected] .org.

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Professional Issues provides readers with brief summaries of nonclinical issues relevant to oncology nurses. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor JeanAnne Johnson Talbert, APRN-BC, FNP, MSN, AOCN®, DHA, at [email protected] mountainstarhealth.com.

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