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Punitive Substance Abuse Policies Increase Risks for Nurses, Patients


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By Jennifer Larson, contributor

February 7, 2011 - A new study published in the Journal of Clinical Nursing has found that punitive substance abuse programs tend to hinder nurses from seeking help to recover from an addictive disorder. In turn, that can put their patients at risk.

Researchers Todd Monroe, Ph.D., RN, and Heidi Kenaga, Ph.D., analyzed the results of several previous studies that reviewed the effectiveness of substance abuse policies for the nursing profession. They found that zero-tolerance policies and other punitive policies promote an atmosphere in which nurses are very reluctant to ask for help.

Their paper, titled “Don’t Ask, Don’t Tell: Substance Abuse and Addiction Among Nurses,” found that supportive programs tend to be much more effective.

“If you can identify the person and remove them from practice (for a recovery program), then you’re really helping the public,” said Monroe, a post-doctoral fellow at the Vanderbilt University School of Nursing in Nashville, Tenn. “You’re also offering them a chance to get back to work.”
According to the literature, about 10-15 percent of the nursing population may have a problem with substance misuse or addiction, Monroe said. Some estimates put the figure as high as 20 percent.

In the past, the culture has not necessarily supported recovery as a primary goal.  Many people did not view addiction as an actual illness; instead they saw it as a moral shortcoming.

Jack Stem, CRNA, the chief executive officer of Peer Advocacy for Nurses, LLC, explained the long-time, prevailing mindset: “This is something that people believe you do to yourself, and you deserve whatever happens to you…if you really wanted to stop drinking or stop using drugs, you would.”

“This is the only disease that I’m aware of where you have to get caught, not diagnosed,” said Stem, who has been in recovery for more than 15 years.

However, the National Institute on Drug Abuse emphasizes that addiction is indeed a disease that can lead to changes in the structure and function of the brain. And it is a costly disease; substance abuse costs the United States as much as a half trillion dollars each year.

Early intervention and assistance are key factors in giving impaired nurses a better shot at recovery—and at being able to keep their jobs and their livelihoods, according to the research that Monroe and Kenaga analyzed.” They propose that these programs can benefit the overall profession, too.

“This is an opportunity to retain professionals in the field when we need nurses,” Monroe said, alluding to the ongoing nursing shortage that has improved in the last few years but is expected to worsen soon.

But alternative-to-dismissal (ATD) programs are not yet universal. And even if a state has an ATD program, not every hospital has such a program. Hospitals don’t have to pursue the ATD route if they have a nurse struggling with addiction or substance abuse, and some choose not to.

Unfortunately, many punitive policies tend to involve lengthy investigations. That can extend the amount of time that an impaired nurse stays on the job while investigators from the state board of nursing or hospital gather information, potentially jeopardizing the health of his or her patients.

“That can take awhile, and during that time, the nurse may or may not be working,” Monroe noted.

The punitive approach is likely also responsible for the underreporting of nurses and nursing students who have a problem. Monroe and Kenaga wrote that is at least partly because “it is considered taboo among many health care providers and nursing school faculty and staff.”

But, “progress is being made,” he added.

Monroe noted that alternative-to-dismissal programs have become much more common in the past 30 years: about 45 states have such programs (or provisions for programs) now.

Also, numerous professional organizations, including the American Nurses Association, the National Council of State Boards of Nursing, the National Student Nurses Association, the American Association of Colleges of Nursing and the International Nurses Society on Addictions, all support ATD strategies, as does the Canadian Nurses Association.

With the help of recovery programs, about 9,000 nurses are probably returning to work each year, Monroe said.

Monroe and Kenaga’s paper advocates for ATD models that include the following components to change the perception of substance abuse from a moral shortcoming to a medical disorder necessitating appropriate treatment:

1. Promoting open communication by discussing substance abuse in every work or school orientation;
2. Encouraging an atmosphere more amenable for reporting by ensuring confidentiality;
3. Providing information about the signs and symptoms of impairment;
4. Conducting mock interventions to help allay fears or feelings of discomfort about confronting a co-worker or fellow student about suspected chemical dependency;
5. Inviting ATD experts to speak to the hospital or school administration; and
6. Participating in scholarly forums about addiction among health care providers.
Stem hopes that nurses’ (and others’) perceptions of nurses struggling with addiction will change, too.

He noted that nurses care for and advocate for their patients, but they also have a responsibility to look out for each other. He cited the American Nurses Association Code of Ethics’ Provision 3.6, which states, “In a situation where a nurse suspects another’s practice may be impaired, the nurse’s duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimal function.”

“To write these people off is unethical and unprofessional,” he said.

Warning Signs of Substance Abuse on the Job

Colleagues can notice certain signs and behaviors that indicate that someone may be suffering from chemical dependency. These signs and behaviors are behaviors associated with substance abuse, according to the American Association of Nurse Anesthetists’ Peer Assistance program:

1. Withdraws from peers;
2. Comes to work on off days and hangs around the drug supply areas;
3. Takes frequent breaks;
4. Increasing or unexplained absences (or tardiness);
5. Gradual decline in work performance;
6. Consistently signs out more narcotics than peers;
7. Displays patterns of inappropriate drug choice and dosages;
8. Increasing mood swings;
9. Increasing difficulty with authority;
10. Forgetfulness, confusion, lacking concentration;
11. Exhibits dishonesty even over trivial matters;
12. Suffers from frequent illnesses or physical complaints;
13. Makes elaborate excuses;
14. Has tremors;
15. Reveals signs of alcohol or drug use such as the smell of alcohol on the breath or wearing long-sleeves even in warm weather;
16. Appears intoxicated at social functions;
17. Is discovered comatose or dead.

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