Prevalence
The prevalence of impaired nursing is difficult to determine for a few reasons. There is a marked shame and stigma often associated with the issue. There is an unwillingness to self disclose information that would label oneself an impaired nurse or one with alcohol and drug problems. There are elements of fear central to the disease of addiction. Nurses are afraid of losing their licenses, termination from their jobs, being judged by coworkers, peers, and patients (Huston, 2010). Furthermore, there is a pronounced lack of research on nursing impairment, making it difficult to estimate numbers. The American Nurse Association has estimated 6-8% of nurses are suffering from addiction and use substances to the extent that it impairs their professional judgment (Talbert, 2009). Monroe and Kenaga (2010) reiterate that nursing impairment is under-researched and under-reported. They currently estimate that 14-20% of nurses may be practicing impaired.
Talbert (2009) discusses that oncology nurses have higher prevalence of impairment because of their exposure to the dying process and death, along with the availability of addictive medications. Monroe, Pearson, and Kenaga (2010) estimate up to twenty percent, or one in five nurses, are impaired. The rates in nurses are higher than the general population of Americans because of the easy access to medications, stress of the job, and a “pharmacological cure” culture that will be discussed in the next section.
Risk Factors
There are some predisposing factors seen in nurses suffering from addictions. Family history of emotional issues and alcoholism seems to be a risk factor (Talbert, 2009). In fact, the general use of alcohol is a predictor for drug use (Huston,2010). People who have a sensation-seeking personality trait have been found more likely to abuse substances (Huston, 2010).
Workplace factors such in the nature of nursing: stressful environment, added job strain of overtime, and long hours, cause some to look for ways of coping. These may be dysfunctional coping methods with alcohol or narcotics (Talbert, 2009). One of the biggest risk factors inherent to nursing is the wide availability of medications. Nurses are trained to use medications to "solve problems" and use them daily to cure and help. There may be a culture ingrained of using pharmaceuticals to alleviate symptoms (Talbert, 2009). Nurses with depression or back pain, especially causing the use of prescription pain medications, can be predisposed to developing addictions (Talbert, 2009).
Treatment Options
For a long time, discipline models were the plan of action for impaired nurses. In 1982, the ANA enacted a resolution to strive for an "alternative treatment" approach, recognizing that drug and alcohol addiction is a disease and those suffering need help and support (Monroe, Pearson, and Kenaga, 2008). Most states now offer treatment options, or diversion programs, as opposed to discipline models. Discipline models are still in place, yet the goal is for voluntary treatment before it gets to the level of an accident causing disciplinary action (Huston, 2010). In California, nurses can self refer into the diversion program, or be referred by family, coworkers, or the board of nursing. The program is voluntary and confidential (Huston, 2010). The goal of these programs is protection of the public, as well as help the nurse recover. Nurses can avoid adverse action on their license if they follow the treatment plan (Monroe et al, 2008). Nurses in alternative programs enter treatment swiftly, and are able to enter recovery and return to work faster. Traditional discipline programs have a long, drawn-out process of investigation and documentation (Monroe et al, 2008). Nurses in alternative treatment programs have been shown to have far better outcomes in recovery.
Role of Staff Nurse when Suspicious of Coworker Impairment
Overall, there is an ethical and legal duty as a nurse to report a coworker suspected of impairment. The nurse reporting is protecting patients as well as the impaired nurse. Nurses oftentimes do not take action because of friendships, work history, fear of confrontation or retribution, and not wanting to jeopardize the nurse's license (Huston, 2010). The first step as a staff nurse and recognizing signs of impairment and notifying a supervisor confidentially, out of advocacy for patients and the nurse in question (Monroe and Kenaga, 2010). By ignoring the problem or not confronting the issue, a nurse is not helping a nurse, despite what one may think. Failing to report could prevent the nurse from getting help he or she needs, and could lead to patient harm or even death.
Indicators of Coworker Impairment
Huston (2010) lists signs of impairment that include a nurse who constantly works overtime or extra shifts, volunteers to care for patients with decreased awareness, the nurse’s patients report their pain is ineffective, narcotic counts may be off, and the nurse may prefer to work in units that utilize narcotics (e.g. emergency department, operating rooms, and oncology department). Behavioral changes are often seen, such as mood swings, change in personal grooming, irritability, defensiveness over medication errors, and interest in narcotics (Huston, 2010). Monroe and Kenaga (2010) list excessive sick calls, tardiness, frequent trips to break rooms or bathrooms, forgetfulness, missed deadlines, poor documentation, and overreaction to criticism as behaviors associated with substance dependency. The more obvious physical signs of impairment include odor of alcohol, sweating, hand tremors, hangovers, unsteady gait, pinpoint pupils, and slurred speech.
Psychosocial Aspects of Re-Entry into Practice
Once a nurse has entered treatment and is in recovery, there are a few psychosocial aspects to consider when re-entering practice, on the part of the nurse and also coworkers and management. Huston (2010) explains the issue of confidentiality must be addressed, as returning nurses are often worried about what their peers will think about them. Huston (2010) explains, "Staff nurses must realize the commitment of the recovering nurse to re-establish his or her career and continue in the profession" (p. 282). Recovering nurses returning to practice need encouragement, support, fair treatment, and privacy (Dunn, 2005). Some coworkers may feel anger, mistrust, disdain, or avoidance toward the returning nurse. This can be diminished with trainings about the disease of addiction and facts about substance abuse. The returning nurse may feel shame or anxiety, and will need a supervised, structured, and supportive environment (Dunn, 2005). The best way to support a returning nurse in recovery is by being inclusive, nonjudgmental, open, and respectful.
References
Dunn, D. (2005). Substance abuse among nurses: Intercession and intervention. AORN Journal, 82(5): 775-798.
Huston, C.J. (2010). Professional issues in nursing: Challenges and opportunities (2nd ed.). Philadelphia, PA: Lippincott Williams & WIlkins.
Monroe, T., & Kenaga, H. (2010). Don't ask don't tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20: 504-509. DOI: 10.1111/j.1365-2702.2010.03518.x.
Monroe, T., Pearson, F., & Kenaga, H. (2008). Procedures for handling cases of substance abuse among nurses: A comparison of disciplinary and alternative programs. Journal of Addictions Nursing, 19: 156-161. DOI 10.1080/10884600802306024.
Talbert, J.J. (2009). Substance abuse among nurses. Clinical Journal of Oncology Nursing, 13(1): 17-19. DOI: 10.1188/09/CJON.17-19.
