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 Impaired Nursing Practice

Impaired Nursing Practice

California State University, Chico

April 26, 2013

Prevalence 

Registered nurses are responsible for the day-to-day care of millions of patients in clinical settings and the risk of impairment is one we must take seriously.  Registered nurses are not immune from the diseases of chemical dependency or mental illness. Experts estimate that at least 10% of the general population will have a problem with alcohol or drugs at some point in their lives (California Board of Registered Nursing (BRN)).  According to Monroe, Pearson and Kenaga (2008), an estimated 16% of Americans suffer from the disease of addiction and in the nursing population the estimate may be as high as 20%. Huston (2010), indicates there are many difficulties that surround prevalence studies, especially that of self-disclosure, the sensitive nature of the information and stigma associated with substance abuse, and it may be more relevant to accept that estimates are estimates and it is better to direct focus to understanding patterns of abuse and achieving positive outcomes.   It is important to note that different sources have different estimates and therefore those estimates may not be reliable.

According to the California Board of Registered Nursing (BRN), the two most frequently received complaints by the BRN pertain to:

“Patient Care - The complainant believes that the registered nurse's actions were unsafe or inappropriate. Serious medication errors, patient abuse, and failure to provide care are examples of patient care complaints.

Chemical Dependency - The complainant believes that the nurse is abusing alcohol or other drugs.”

The sad and difficult fact is that impaired nursing not only affects the nurse but also specifically can potentially harm the patients nurses are supposed to be taking care of.  The question to consider would be if the nurse is impaired and not providing proper care, what is the appropriate next step.  According to Kunyk and Austin (2011), research has identified addiction as a brain disorder characterized by compulsive drug seeking and use; prolonged use may induce a chronic, relapsing disease - a health problem requiring treatment rather than punishment.

Risk Factors

Health care professionals, including registered nurses, may be particularly susceptible to substance abuse problems due to the stresses of working in a health care environment and due to an increased opportunity to obtain controlled substances (BRN).  Huston  (2010) states nurses have constant access to narcotics; fatigue comes with the job, regardless of the shift one works and many nurses work hard to get experience and increase their knowledge.  According to Kunyk and Austin (2011), studies suggest the high job strain that comes with nursing, the disruption and fatigue related to shift work, the ease of access to medications and knowledge of their effects, as well as practice in certain specialties can be factors associated with addiction.  

Darbro and Malliarakis, (2012), indicate the top four risk factor for nurses in the workplace are access, stress, lack of education and attitude.  Nurses have ready availability of drugs.  Nursing is a highly stressful occupation; shift work, and long work hours lead to fatigue, sleep deprivation, circadian rhythm disruption and other psychophysiological consequences (Darbro and Malliarakis 2012).  The lack of education on the addictive process and the signs and symptoms is one of the more profound and overlooked risk factors for nurses.  It is common for health care professionals to hold the most negative view of colleagues with substance use disorders; this in turn may create a work environment in which impaired nurses may take even greater pains to conceal their abuse, and increasing the risk of harm to all (Darbro and Malliarakis, 2012). Attitude is the fourth top risk and may be the most important factor.  Nurses may see substance use as an acceptable means of coping with life’s problems and a way of promoting enjoyment, comfort and the ability to get along.  Nurses may develop a faith in drugs as a means of promoting healing (nurses training and observations).  Nurses may have a sense of entitlement that focuses on the nurse’s need to continue working and thus rationalization regarding drug use.  Nurses see themselves as caregivers and not receivers, they may feel invulnerable to the illness of their patients. Professional training involving powerful drugs leads to an acceptance of self-diagnosing and self-medicating for physical pain and stress (Darbro and Malliarakis 2012).   

Treatment Options

Historically, the disciplinary approach was the norm in most states through the 1980’s, (Huston 2010).   According to Monroe et al., (2008), the disciplinary approach is designed to penalize nursing professionals who are impaired and prevent them from practicing; this approach is a way to protect the public from harm.   However, there is little attempt to advocate for the individual nurse or provide treatment or rehabilitation because the focus is on discipline.  According to Kunyk and Austin (2011), in the past, nurses with addiction have been disciplined, lost their licenses, terminated involuntarily, denied employment and even incarcerated.  In 1982, the American Nurses Association (ANA) offered to support treatment of chemically dependent nurses and many states began to look at treatment and rehabilitation options instead of discipline (Huston 2010).  Monroe et al. (2008) states ANA adopted a resolution in 2002 reinforcing its commitment to alternative-to-discipline programs and encouraging each state to adopt non-punitive strategies to address the disease of chemical dependency among nurses.  

Many states have treatment options and programs may vary from state to state.  California’s BRN has a Diversion Program and it aims to identify symptoms, intervene and change outcomes.  Over 1,200 registered nurses have successfully completed the program. To complete the Diversion Program, a chemically dependent nurse must demonstrate a change in lifestyle that supports continuing recovery and have a minimum of 24 consecutive months of clean, random, body fluid tests. A nurse with a history of mental illness must demonstrate the ability to identify the symptoms or triggers of the disease and be able to take immediate action to prevent an escalation of the disease (BRN).  The success of the Diversion Program is due to close monitoring of participants for an average of three years, but more importantly, it is attributable to the encouragement, support and guidance provided to nurses by other nurses (BRN).  Huston (2010) indicates both Texas and Michigan have programs that are independent from the states licensing board and are confidential.  There are benefits to the different programs and they are definitely better than discipline because there is the possibility of retaining or re-entry of the nurse.   

Psychosocial Aspects of Re-entry

Encouragement, support, and guidance for the registered nurse in recovery is an effective alternative to disciplinary action, and determination that the registered nurse is able to resume nursing practice (BRN).  Providing confidentiality to nurses with addiction is a fundamental condition of mutual respect, a critical measure of reducing stigma and a necessary condition for nurses to recognize and seek treatment for their serious illness (Kunyk and Austin 2011). By giving support and confidentiality it will help the impaired nurse to not have a relapse when they re-enter the work force.  Kunyk and Austin (2011) indicate confidential agreements provide for return to practice following successful treatment and may be conditional on commitment in long-term aftercare (5 years) programs.  These programs usually consist of monitoring for early detection of relapse through random drug screening and continued engagement in ongoing treatment.

According to Monroe et al. (2008), nurses should also advocate for colleagues whose job performance may be impaired to ensure that they receive appropriate assistance, treatment and access to fair and legal processes, including supporting the return to practice of the nurse who has received assistance and is ready to resume her duties.  We as nurses must be open and compassionate for all, including fellow nurses who are in need of substance abuse treatment.  Darbro and Malliarakis (2012), indicate close evaluation of emotional reactions to the "hurdles" of recovery should be implemented, specifically issues like dealing with guilt, shame, anger, depression and insomnia.  It is also important to pay attention to other compulsive behaviors that may emerge such as gambling, food, sex or work addictions and also identification of weak points in the nurses' recovery and always provide support (Darbro and Malliarakis 2012).  Nurses are also human and we must accept we are vulnerable to addiction (even though we think we are not vulnerable), but we are also capable of recovery.

Indicators of Co-worker Impairment

      Huston (2010) indicates there are several signs suggesting chemical impairment including the following common signs of impairment; the nurse appears to be a “workaholic,” arriving early, staying late, and offering to work extra shifts; a nurse often works in areas that have a high volume of commonly abused drugs; examples include the oncology department, the emergency department and the operating room.  The nurse may volunteer to care for patients who have diminished awareness and there are many reports from patient stating their pain medication is not working;  there are narcotic count errors often and coworkers may complain about the quality and quantity of the nurses work. Monroe and Kenaga (2010) also indicate some additional things to be aware of like attendance, including frequent absences and tardiness; frequent trips to rest room/locker room; confusion about work schedules and frequent accidents on the job. 

        Some behavioral changes to be aware of may include an increased irritability with patients and colleagues, often followed by extreme calm. Social isolation; the person eats alone and avoids unit social functions. Extreme and rapid mood swings. Unusually strong interest in narcotics or the narcotic cabinet. Sudden dramatic change in personal grooming or any other personal habits.  Extreme defensiveness regarding medication errors (Huston 2010).  Monroe and Kenaga (2010) state performance issues like assignments requiring more time to be completed; difficulty recalling/understanding instructions; alternate periods of high and low activity; increasing inability to meet schedules and deadlines.  An impaired nurse may also over react to criticism and has a tendency to blame others; may have frequent medication errors and is defensive when questioned about those errors (Monroe and Kenaga 2010). Some personal behavioral issues may be poor hygiene, drowsiness at work, incoherent or irrelevant statements, and deteriorating relationships.  Physical signs may include hand tremors, excessive sweating, marked nervousness, slurred speech, coming to clinical intoxicated or smelling like alcohol and increased anxiety (Monroe and Kenaga 2010).  

        It is important for nurses to be aware of the indicators of impairment and to have open communications about the signs and symptoms and what to do when we suspect a problem.

Staff Nurse Role-Suspicions of Co-Worker Impairment

According to Huston (2010), the position of ANA and other nursing organizations is clear: It is the ethical and legal duty of a nurse to advocate for public safety, their colleagues, and the profession.  In other words, it is a nurse’s job to protect patients from harm and if that means reporting an impaired nurse than it must be done.  Huston (2010) also refers to “code of silence” stating that in the reality of practice it is often not an easy obligation to comply with.  Some barriers to coming forth are “established friendship, work history, loyalty, fear of confrontation, and fear of jeopardizing a colleague’s license to practice; also fear of being labeled a whistle-blower or just inability to accept that an educated and skilled practitioner is diverting drugs for personal use (Huston 2010).  Nurses are caring and loyal and dedicated to doing the right thing and sometimes the right thing may be difficult when it involves a coworker who is impaired.

According to the BRN, most people suffering from chemical dependency or mental illness deny the problem and many times they are the last to recognize and admit that they need help. If mental illness or chemical dependency problems are left untreated, they may eventually jeopardize patient health and safety. They can also threaten the life of the person afflicted (BRN).  In these cases, it becomes imperative that those individuals who detect a chemical dependency or mental health problem in a registered nurse take action. Without intervention, diseases have predictable courses and outcomes. 

 References

Darbro, N. and Malliarakis, K. (2012). Substance abuse: Risks, factors and protective factors.  Journal of Nursing Regulation, 3(1), 42-48.

Huston, C. (2010).  Professional issues in nursing: Challenges  & Opportunities (2nd ed).  Philadelphia: Lippincott Williams & Wilkins. 

Kunyk, D. and Austin W. (2011).  Nursing under the influence: A relational ethics perspective.  Sage, 19(3), 380-389.

Retrieved from http://www.rn.ca.gov/enforcement/whatisenf.shtml.  Accessed 4-20-2013.

Monroe, T. and Kenaga, H. (2010). Don't ask don't tell: Substance abuse and addiction among nurses. 

       Journal of Clinical Nursing, 20, 504-509.

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.

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