Sarah isn't sure how she got to this point.
As a nurse, Sarah works in a high-stress environment and recently went
through a difficult divorce.
After a back injury, Sarah began taking pain medications
prescribed by her doctor.
When her prescription ran out, she began borrowing medications
from floor stock, then using medications that should have been discarded.
And now, Sarah is diverting medications intended for her patients and attempting
to conceal that diversion from co-workers and supervisors.
Sarah's story illustrates one of the most serious problems facing
the nursing profession today.
Substance use disorder, nurses who abuse substances pose a unique
challenge to the profession.
The behavior that results from this disease has far-reaching and negative
effects not only on the nurses themselves but also upon the patients who depend
on the nurse for safe, competent care.
Substance use disorder among healthcare providers also creates significant legal
and ethical responsibilities for colleagues who work
with these individuals.
But there's good news too.
When employees think their supervisor knows how to detect substance use and is
willing to do something about it, employee's drinking and
drug use decreases.
Your role as a colleague or supervisor of the nurse who has a substance use
disorder is pivotal.
Be armed with knowledge.
First, identification and reporting of the problem.
Next, intervention.
Then, diagnosis and treatment of the substance use disorder.
And finally, monitoring of the nurse after return to practice.
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Substance use disorder encompasses a pattern of behaviors that range
from misuse to dependency or addiction, whether it's alcohol, legal drugs,
or illegal drugs.
Addiction is a complex disease with serious physical, emotional, financial,
and legal consequences.
It can affect anyone regardless of age, occupation, economic circumstances,
ethnic background or gender.
Substance use disorder is a progressive and chronic disease,
but also one that can be successfully treated.
Although alcohol is the drug of choice for the general population,
nurses have increased access to controlled substances contributing to higher
incidents of dependence on them regardless of the chemical.
Mind-altering substances results in long-lasting changes to the brain,
which is why addiction is a chronic and relapsing brain disease.
The earlier substance use disorder in the nurse is identified and treatment
is started, the sooner patients are protected, and the better the chances are
of the nurse returning to work.
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Nurses and other healthcare professionals have about the same prevalence
of substance abuse and addiction as the general public, but there are unique
workplace factors that actually increase a nurse's opportunity
and risk for addiction.
Staffing shortages, increased patient acuity and assignment ratios,
demands from administrators and physicians, shift rotation,
and long work hours.
All of these issues make nursing a highly stressful profession.
In addition, some nurses are subject to workplace bullying and verbal abuse
contributing to stress and feelings of powerlessness.
When someone is also experiencing personal problems or lacks effective coping skills,
this job-related stress may contribute to substance use.
Nurses also have relatively easy access to controlled substances
and other drugs of abuse.
Oftentimes, the lack of institutional controls for storing and distributing
narcotics facilitates the improper removal of drugs from floor stock, waste,
or even from a patient's medication supply for the nurse's personal use,
also known as diversion.
Many nurses use their education and experience to treat their own symptoms.
Because of that knowledge, they may have a false sense of confidence
and a belief that they can control their use of drugs.
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It's not always easy to recognize unsafe practices in a nurse
with substance use disorder.
Sometimes it's tough to differentiate between the subtle signs of impairment
and stress-related behaviors.
Three things to watch for are behavior changes, physical signs,
and the diversion of drugs.
Behavioral changes can include shifts in job performance like absences from the
unit for extended periods, frequent trips to the bathroom,
arriving late or leaving early, and an excessive number of mistakes
including medication errors.
Behavioral changes can also include subtle changes in appearance that escalate
over time, wearing long sleeves in warm weather, increasing isolation
from colleagues, inappropriate verbal or emotional responses or
diminished alertness, confusion or memory lapses.
When nurses are using drugs and unable to obtain them from a treating physician,
they may turn to the workplace for access or diversion, often
causing narcotics discrepancies.
These might include incorrect counts, large amounts of wastage,
numerous corrections of records, frequent reports of ineffective
pain relief from patients, offers to medicate co-workers' patients
for pain, altered verbal or phone medication orders, and variations
in controlled substance discrepancies among shifts or days of the week.
Nurse managers and colleagues often don't recognize the warning signs of a substance
use disorder in a nurse co-worker.
They may misread cues and look for other explanations for behaviors.
In fact, many nurses with substance use disorder are unidentified, unreported,
untreated, and continue to practice.
This finding highlights the need for education about substance use disorder
for all staff members.
It's especially important for the nurse manager to be able to address the signs
and symptoms of substance use disorder in a transparent, supportive way.
Nurse managers should work to encourage open dialogue and educate staff that
substance use disorder is a medical condition, not a personal failure.
Nurse managers are also responsible for ensuring that co-workers understand they
have a professional and ethical responsibility to report a colleague's
suspected drug use to the nurse manager and in some states or jurisdictions
to their board of nursing.
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A nurse who has harmed patients or like Sarah has created a risk of harm because
of substance use may need to be separated from practice and mandated to seek
treatment and fulfill other requirements.
Many boards of nursing offer non-punitive Alternative-to-Discipline Programs, ADPs,
which are voluntary non-disciplinary opportunities for nurses
with substance use disorder.
ADP approaches which have been in place for more than two decades,
give nurses an opportunity for rehabilitation.
Unlike the more traditional disciplinary actions, ADPs have the benefit of avoiding
a long period of investigation in which the nurse can still practice
and still place patients at risk.
Because ADP requirements are determined in a private agreement,
they can help break through the denial of a nurse who fears the public
notoriety of discipline.
Nurses in these programs stay fully accountable to themselves,
a program monitor, a counselor, other nurses, and supervisors.
Sarah is fortunate because when she returned to practice,
her supervisor was well-oriented to her responsibilities in the ADP.
Her supervisor even completed specialized training that increased her knowledge,
sharpened her observation skills, and increased her willingness to assist
Sarah in her return to work.
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Treatment for substance use disorder does work and nurses in recovery can reenter
the workplace safely when treatment and monitoring are instituted.
Research demonstrates that substance use disorder is treatable and that successful
long-term recovery is possible for all who maintain a rigorous
relapse prevention program.
Because addiction causes changes in the brain, relapse is always a possibility.
Continuing care activities provide the nurse with professional support
for relapse prevention.
These activities typically include periodic random drug testing and
documented attendance at 12-step programs, professional support groups,
and even individual counseling.
Similar to participation in an Alternative-to-Discipline Program,
the nurse returning to work is subject to very structured and specific guidelines.
A return to work contract will identify a workplace monitor, standards
for work performance, and conditions of employment
and require drug screening.
It may also set restrictions on practice, like restricted access to controlled
substances or not working in the night shift.
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Substance use disorder is a challenging and complex issue
for the nursing profession.
But with supportive and educated supervisors and colleagues,
nurses with this disease can be identified more quickly and receive
the help they need.
The combination of identification, successful treatment,
and careful monitoring ensures that the public is protected and allows recovering
nurses like Sarah to safely return to practice.
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