Is Your Nursing Colleague Impaired

Alcohol and Drug use in the Workplace

   Impact and Indicators

   After completing this lesson, you will be able to:
Assess the impact of impaired nursing practice on patient safety; 
Describe behaviors that indicate a nurse* may be working while impaired by drugs or alcohol;
Summarize the actions to take when you suspect a nursing colleague is practicing while impaired.
   While much of the information in this lesson may apply to a range of health care providers,  it is focused toward licensed nurses.

 

For Maria, it started when she hurt her back  lifting a patient; it’s hard to work when you’re always in pain.
Amy has struggled to hide her anxiety and depression for years and be the “perfect nurse”; now she’s a nurse manager and her stress level is even higher.
Ted started binge drinking in college and still does it to relax on weekends; because he graduated at the top of his class he always thought he could control his drinking. He’s starting to come in late or call in sick on Monday mornings…and always has a new excuse.
Maria, Amy and Ted are part of a small but significant percentage of nurses who jeopardize patient safety by working while impaired by drugs or alcohol.

Definition

How would you define or describe an impaired nurse?
Take a moment to think about this question.
Here are some responses from nurses working in the field.

Art:      Well, my initial definition of an impaired nurse is someone who we see changes in their behavior, changes in how they work with the patients.  I think that's the main thing, and one thing about nurse anesthetists, I think about nurses in general, we're all concerned about each other as far as drug abuse is concerned.

Kris:     An impaired nurse is someone(?) who is unable to do his or her job because they are under the influence of something that is affecting their abilities.

Linda:   Well, there are two different questions here.  One is define and one is describe, and I think if I were to define what an impaired nurse was, I would have to say it is a nurse that is working with patients, making decisions with an impaired or altered state of mind caused by the use of a mind-altering substance, and that's very different from my description of an impaired nurse, which is basically I don't feel that there is a clear description of an impaired nurse.  Nurses who are impaired do not have a classic presentation.  It can be the smartest nurse on your unit.  It can be the nurse that is in charge of the floor.  It can be a…it can be, you know, the nurse that is coming to do consults on patients, and there is not a clear classic description of what that impaired nurse looks like, and I think that's where we often make poor judgment.  If we are suspecting a behavior and that nurse does not fit a description of in our minds what we think an impaired nurse would look like, we can miss an awful lot of opportunities to intervene when someone is impaired.

Nate:    In the broadest terms?  A nurse is impaired when he or she loses focus on the patient.  This doesn't happen often.


   American Nurses Association (ANA) definition:
Is unable to meet the requirements of the code of ethics and standards of practice of the profession. 
Has cognitive, interpersonal or psychomotor skills affected by psychiatric illness and/or drug or alcohol abuse or addiction.

While there is a range of ways to define an impaired nurse, this lesson focuses on nurses who provide patient care while impaired by drugs or alcohol.  Other common terms for impairment by drugs and alcohol are substance abuse or chemical dependency.

Substance abuse:  Overindulgence in, or dependence on, addictive substances, especially alcohol or drugs. 
Chemical dependency:  Also known as addiction; the compulsive use of a substance (drugs or alcohol) periodically or continuously to experience the psychological or physical effects, despite negative consequences. 

10 % of the general population is  dependent on drugs or alcohol.
2.5 million RNs are employed in the US.
10 % of RNs are dependent on drugs or alcohol.
6 % provide patient care while impaired.
Estimates are approximate

Other important points:

While reports of prevalence vary, substance abuse among nurses is believed to be consistent with that of the general population.  Some nursing specialties (e.g. anesthesia, oncology, critical care & psychiatry) may have a higher prevalence of substance abuse because of intense emotional and physical demands, as well as the increased availability of controlled substances.   Some reports suggest that nurses may have a higher prevalence of drug abuse and a lower prevalence of alcohol abuse.

Impact on Patients

Nurses are the largest component of the healthcare workforce.
They are intrinsically linked to the care and safety of patients.
   The ANA recognized the effect of impaired nurses on patient safety when it resolved to:  “Increase awareness of the health and patient safety risks associated with untreated addiction…”

   How can a nurse who is working while impaired affect patient safety?
   Take a moment to think about this question.
   Here are some responses from nurses working in the field.

Art:      Well, this I think is a very serious problem because first of all perhaps they're not thinking of the right drug dosage to give the patient because what they're doing is they're giving the patient perhaps saline or something and taking the fentanyl or the drugs for themselves, and therefore they're becoming impaired while working with that patient, so therefore that patient isn't getting the total care that that patient needs.

Linda:   Okay.  I think nurses working with, ah, while impaired definitely is working with impaired judgment and is paying very poor attention to details.  It is the nature of having an altered substance in the brain, in the body, you're not making great judgment about decisions, and when you are working as a nurse the details and the attention is of utmost importance.  I can give you some examples in my background.  I was working with a nurse who I was always quite suspicious of her ability to function and thought that likely she was coming to work impaired, and at the end or in the middle of a shift when I was working in the intensive care unit there was a code called into a room, and it ultimately ended up being the result of a nurse, of this nurse, having switched IV bags and not giving the appropriate medication.  Instead of Lasix being given, she was…the patient was given some potassium, and there was a very, very critical moment where this patient was very critically effected.  Fortunately survived, but that taught me an awful lot about intervening when I have a sense, a suspect, or a sense of suspicion about a nurse's judgment.  I've worked with many nurses who are impaired who have a number of late…who arrive to work late, who want to leave early, who make lots of excuses for not being able to work during holidays, and over a long period of time we started to see patterns and you become, you know, become somewhat suspicious of the details of responsibility that often are not met when someone's impaired.

Nate:    The obvious one is that if you're diverting pain medicine from the patient, it can prolong the time to recovery…oh, boy.  I'll start again.

Kris:     Generally, alcohol could impact the nurse's judgment.  In nursing we make a lot…we do a lot of decision making.  We assess the patient and then based on our assessment we make a plan of care, and both the ability to do these assessments successfully and then to interpret what you have learned about the patient and then develop a plan of care could be impacted if the alcohol or drugs was affecting judgment, thought, memory, the ability to accurately identify what's going on in the situation.


Impaired nurses can jeopardize patient safety by:

   Research shows that some “nurses with substance abuse disorders experience blackouts, confusion, or periods of memory loss at work”

   Even though some nurses appear to function well while impaired by drugs or alcohol, the potential for harm still exists.

Case Study

“I used for four years at one hospital and left there because I was getting “out of hand” and was worried that I was going to get caught. Although I had tried to stop, I had not been able to. So I found a job that had much less access to drugs.

I worked for five more years before getting caught.  Later I found out, that when I left there was a core group of nurses who all agreed that I probably had a problem with drugs/alcohol, based on my behaviors.

But because I was the charge nurse, did an excellent job, was well respected by all I worked with (attending MDs, fellows, residents and med students, patient care technicians, the charge nurses I had to deal with on other floors, and co-workers), these nurses were reluctant to address the issue.

I sought these nurses out after I found this out---there were two still working there. They said they did not want to “hurt my feelings” and were reluctant to believe that I could have a problem.

I did not act like the “street bum picture” so many have of addicts.  They think that all addicts act like a drunk or high person if addicted, and are not aware that so many of us work functionally for a long time, causing no harm to patients (only by the grace of God), but still very much in need of help.”

Impact on Nurse

Chemical dependency is a primary disease process that has five traits:

  1. Compulsion/uncontrolled use
  2. Loss of control/persistent desire
  3. Persistent use despite adverse consequences
  4. Withdrawal symptoms
  5. Tolerance:  need for greater amounts

   Chemical dependency is chronic, progressive and treatable.

Impacts of chemical dependency

Health

Professional Practice

Personal Life

· Diabetes
· Hypertension
· Cardiovascular disease
· Traumatic injuries
· Liver and other diseases
· Death from overdose, suicide or injuries

· Increased risk of harming patient(s)
· May lose respect & trust of colleagues
· Loss of self respect
· May be fired, suspended and/or placed on probation
· Loss of income and seniority
· May lose license
· Will be monitored if allowed to return to practice

· Low self esteem
· Increased risk for anxiety and depression
· Family and other relationships suffer
· Financial problems
· Legal issues

 

Why are Nurses at Risk?

   Impaired nurses share some contributing and predisposing factors with the general population:

They also have some risk factors that relate to their profession:

Indicators of drug abuse

 

Indicators of alcohol abuse

Exhibiting one or more of these behavioral indicators does not necessarily indicate drug or alcohol abuse or addiction.
Recurring behaviors or patterns can create an "index of suspicion" that must be taken seriously

Other Important Points.

What are the most commonly abused substances?
Alcohol is the most frequently abused substance. Commonly abused drugs include amphetamines, opioids (often fentanyl), sedative/hypnotics, tranquilizers and inhalants.

How do nurses obtain controlled substances?
Legal methods
    Legitimate prescriptions are written for them.
Illegal (diversionary) methods on the job
Diverting drugs that are on their way to a specific patient.
Diverting from supply locations, including drug-dispensing machines.
“Workplace theft has been identified as the most frequent source of illegally obtained narcotics.” 

Your Professional Responsibility

What should you do if you suspect a colleague is working while impaired by drugs or alcohol?

As a licensed professional, your primary responsibility
is the care and safety of patients.
You are legally and ethically required to report violations of your state’s nursing code and statutes that put patients at risk.
   “Nurses must be vigilant to protect the patient, the public and the profession from potential harm when a colleague’s practice, in any setting, appears to be impaired.”  ANA Code of Ethics, Provision 3.6
   If you suspect that a colleague is working while impaired, the ANA suggests that you:
   Consult supervisory personnel;
Follow organizational policies for documenting or reporting;
If organizational policies are non-existent or inadequate, consult your professional association, state peer assistance program, employee assistance program or a similar resource.

Reporting Can Be a Positive Step

Reporting  a colleague who is working while impaired can ultimately help the nurse enter treatment with the goal of returning to the nursing workforce.
Reporting also helps protect:

Summary

   Some nurses jeopardize themselves and impact patient safety by working while impaired by drugs or alcohol. 
There are on-the-job indicators for drug and alcohol use. 
It is your ethical and legal responsibility to report a colleague you suspect is working while impaired.

Credits:
Content Author:
Mary Jo Willis, MS; University of Wisconsin-Madison School of Nursing
Production: C.K. Worrell, BFA Visual Production
Peg Volkmann, MA Senior Editor
Jeannette McDonald, DVM, PhD Creative Director
With Support From: The Fund for The Improvement of Postsecondary Education (FIPSE) U.S. Department of Education
NEAT,   Nursing Education And Technology   www.neatproject.org

References:
American Nurses Association, (2002), ANA resolution 3, International Conference on the Addicted Nurse. Retrieved 5/30/2006 from http://brucienne.com/nir/ANARESOLUTION.htm
American Nurses Association, the Center for Ethics and Human Rights. (2002). Code of Ethics for Nurses, with Interpretive Statements. Washington, DC: American Nurses Publishing.
Dunn, Debra. (2005, October). Substance abuse among nurses--defining the problem. AORN Journal, vol. 82, #4.
Dunn, Debra. (2005, November). Substance abuse among nurses--intercession and intervention. AORN Journal, vol. 82, #5.
Dwyer, Dede. (2002). “Why didn’t I know?” the reality of impaired nurses.” Connecticut Nursing News, Mar-May. Retrieved 6/27/06 from
http://www.findarticles.com/p/articles/mi_qa3902/is_200203/ai_n9046754/print
Exnursie/Registered User. (2004, November 6). “Has your nursing license ever been in jeopardy?”[Msg 10]. Mes­sage posted to http://allnurses.com/forums/f118/has-your-nursing-license-ever-been-jeopardy-83746.html
Pavlovich-Danis, Susanne J. (2006). “The impaired nurse.” Retrieved 7/11/2006 at
http://www2.nurseweek.com/CE/self-study_modules/tools/print.html?CCID+3045
Trinkoff, Alison M, and Carla I. Starr. (1998). Substance abuse among nurses: differences between specialties, American Journal Public Health, 88: 581-585.
U.S. Dept. of Health and Human Services, Health Resources and Services Administration, Bureau of Health Pro­fessions. (2007). Preliminary Findings: 2004 National Sample Survey of Registered Nurses. Retrieved 1/4/07 from http://www.bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm