HOW TO RECOGNIZE AN IMPAIRED COLLEAGUE
SITUATION ONE: You dread going to work because the nurse on the previous shift often leaves you with incomplete charts and patients complaining about pain. No wonder he's worked at three different hospitals in five years.
SITUATION TWO: A nurse on your shift has become moody, takes frequent bathroom breaks, and no longer wants to socialize with colleagues. She's often late for work, and her once-neat handwriting has become sloppy.
SITUATION THREE: She's the best nurse on the floor. Patients, hospital administration, and physicians love her. She often volunteers to work extra shifts and prefers acute-care units where drugs are frequently administered.
You have just noted behaviors of colleagues whose nursing practice could be impaired by drugs or alcohol.
Following are some signs indicating that a colleague may be impaired, according to Linda Barile, BSN, MN, PhD, a program director of HAVEN, a confidential program for licensed healthcare professionals with drug addiction and mental health problems in Connecticut:
» Changes jobs frequently
» Prefers night or off-shifts where there is less supervision and more access to medication
» Pinpoint pupils or glassy-eyed
» Smells of alcohol or makes excessive use of breath mints and mouthwash
» Falls asleep during meetings or has trouble focusing on work
» History of chronic pain from an injury or recently had surgery
» Good relationships with doctors who may prescribe medication for them
» Significant family problems
» Often volunteers to administer narcotics to patients
» Patients may complain of inadequate pain relief
» Incomplete charting and practice errors
» Anxious to work overtime or extra shifts
» Can be moody or isolated, lethargic or high-strung
Barile estimates that 90% of the nurses she sees in her work at HAVEN come into the program with chronic pain. All too often, she said, addiction is a risk for nurses who take medication in the longer term so they can deal with chronic pain, or they may have other comorbidities, such as mental illness.
Anyone is at risk of addiction, no matter whether he or she is young or older, an LPN or RN, or has a master's degree or PhD, Barile said. "First the person takes the drug, and then the drug takes the person."
What are nurses' attitudes about addiction in their ranks?
Ultimatenurse.com, an information and discussion forum for nurses, invited RN to conduct an online survey of its registered members to find out. The 10-question survey, posted Feb. 18-20, 2009, netted 313 responses. Here are the questions and a summary of answers:
1) HAVE YOU EVER WORKED WITH NURSES YOU FELT WERE ADDICTED TO DRUGS?
Fifty-nine respondents said they had worked or are working with nurses impaired by drug addiction. Several nurses said they had supervised other nurses who had returned to work following treatment for addiction. Eighty-eight said they were certain they never worked with drug or alcohol-addicted nurses. Others were not certain, given the strict privacy policies at their facilities. Some commented that keeping addiction problems private was challenging when nurses would return from a leave of absence, were supervised by others, and no longer had access to narcotics. "Once that happened, entire shifts would know," one respondent said.
2) HAS PATIENT CARE BEEN AFFECTED BY NURSES WITH DRUG-ADDICTION PROBLEMS AT YOUR FACILITY?
A total of 76 said drug-addicted nurses had hurt patient care at their facilities by diverting pain medications, failing to recognize changes in patient assessments, and making medication errors.
3) HOW GOOD ARE EMPLOYEE-ASSISTANCE PROGRAMS (EAPS), PEER-SUPPORT, AND REHABILITATION SYSTEMS AT YOUR FACILITY TO HELP DRUG-ADDICTED NURSES RECOVER?
Most said they had no personal knowledge of these support systems. However, 39 reported good-to-excellent EAPs, peer-counseling, and rehabilitation resources. One remarked, "If the nurse realizes there is a problem and goes to the nursing supervisor, there is a lot of support." A total of 56 rated their programs and support of drug-addicted nurses as fair, poor, or nonexistent. "I had to look for help and support outside the facility," said one respondent. Nurses in such facilities tended to report that nurses with addiction problems were fired. One commented, "My employer at the time of my active addiction chose to fire me, thus saying it was no longer their problem." Some said that because of the stigma of drug abuse and fear of losing their licenses, they left their jobs before employers found out about their addiction. One noted, "I quit before I found out about the EAP and peer-support program. I was so scared. I went into rehabilitation on my own."
4) HAVE YOU EVER BEEN ADDICTED TO DRUGS?
Twenty survey participants reported problems with addiction. Most of these said they have been in recovery for years and successfully returned to full practice. One chose to practice nursing in areas where narcotics are not administered. Another works in a drug-rehabilitation facility. However, one respondent gave up nursing for fear of relapse.
5) DO YOU HAVE RECOVERED NURSES AT YOUR FACILITY?
Most respondents said they didn't know of any. Others have worked with several nurses who were supervised during their recovery and are now "doing fine." A few reported that they worked with nurses in recovery who relapsed and ultimately lost their licenses. One nurse said she worked with a colleague almost a decade ago who was heavily supervised and restricted from dispensing narcotics: "Some nurses were supportive, but others were rude and agitated at the prospect of having to pass controlled substances for that nurse. The verbalization was 'She shouldn't be here if she can't do her full job.'"
6) WHAT CAUSES NURSES TO BECOME ADDICTED TO DRUGS, IN YOUR VIEW?
The overwhelming response was "stress"—from work and family responsibilities, coupled with a predisposition toward addiction and availability of drugs at work. One nurse commented that many nurses are the "big breadwinners, adding stress to an already stressful career." Another said some nurses have come back to work following injury or surgery, still in pain and on medication. That plus working in a high-stress environment with the controlled substances available "sets nurses up for addiction." A third felt that every profession, not just nursing, comes with its own set of stressors: "Drug use provides an 'escape' from reality," and is easier than doing the "difficult internal work of developing safer and more appropriate coping skills."
7) DO YOU FEEL THAT OTHER STAFF MEMBERS—SUCH AS PHYSICIANS, FOR INSTANCE—WHO ARE ADDICTED TO DRUGS GET TREATED DIFFERENTLY FROM NURSES?
This question got a spirited response, with many nurses reflecting a comment from one participant who said, "Doctors generate a lot of money for hospitals. Indeed, they are treated differently." Some nurses felt that doctors tended to cover for one another and have the financial resources to obtain better treatment for addiction. Other nurses said they did not know or felt that treatment was fairly equal among all hospital staff.
8) WHAT KEEPS NURSES FROM SELF-REPORTING IF THEY ARE ADDICTED TO DRUGS?
The overwhelming response was "fear": of job loss, losing one's license and livelihood, losing respect of peers, family, and friends, and lifelong stigma. A few others cited "denial." They said the addiction process prevents nurses from knowing they have a problem. One commented, "Nurses are human. Most individuals don't self-report drug addiction until they reach rock bottom or are caught."
9) DO YOU BELIEVE THE INCIDENCE OF DRUG ADDICTION AMONG NURSES IS GROWING?
Responses were mixed. One participant who has been a nurse since the 1960s said, "I work with the same percentage of addicted nurses now that I have always worked with." Another nurse felt that addiction problems will continue to grow: "There is a reason there is a nursing shortage. It's a very, very difficult and taxing job. You need a lot of personal resources and support to do it well and to remain whole." A few nurses said the advent of automated medication and supply-management systems has helped to reduce the incidence of drug addiction.
10) DO YOU BELIEVE THAT YOUR FACILITY IS TOO SOFT OR TOO HARD ON NURSES WITH DRUG PROBLEMS?
One nurse responded that facilities in general are too soft. "I believe that healthcare professionals are in a unique and privileged position to have access to narcotics. We should be fiercely protecting patients from healthcare professionals who are high on drugs, as they are impaired and cannot provide a high level of care." Others felt that state boards of nursing have become too punitive, without a balance of consequences and support. "I would make professional nurse support groups more easily accessible and mandatory for the duration of the consent agreement. I would mandate 12-step recovery meetings during and after mandated treatment. There would be a committee within the board to do case management on nurses needing supervision. The contract I signed ... included all this and more, and kept me compliant until I wanted to be, until I got past the shame and fear." Several felt that facilities were tough on those who were caught but often take too long to investigate nurses who are suspected of substance abuse. Some nurses were frustrated when reporting suspected drug-abuse problems. One was made to feel like a "troublemaker." Another was told, "We're working on it. We need more proof." Three respondents recommended random drug screens for all nurses to detect problems at an earlier stage, rather than singling out a certain nurse who is suspected of drug abuse, or waiting until patient care is compromised. One commented that nurses with drug-abuse problems should be treated "like human beings with an illness rather than as criminals. A little compassion, my friends. ... We have all stumbled and fallen short."