Substance Abuse in Nursing Puts

Substance Abuse in Nursing Puts Patients at Risk

The nursing profession is one that is staunchly backed by advocate organizations and groups, which look out for the rights and well being of their professionals. The American Nurses Association's (ANA) online Journal lists as its primary dictum, "First, do no harm (ANA, 2009)." The dictum is in regard to the numerous patients that enter physician offices, clinics, or hospitals, either by way of a physicians order, or through the Emergency Department (ED) of a hospital (often referred to as "emergency room or ER). Under the strict oversight of managed care today, no patient is admitted to a hospital inpatient setting without having first been assessed for that specific level of care. Patients entering through the ED are often in recent or immediate onset of medical crisis, and must still be certified by managed care for medical necessity to justify admitting the patient to an inpatient level of care. Either way, by a physician's order for a direct admission, or admission through a hospital ED, the oversight by managed care organizations certifies the acute condition suffered by the patient that warrants the care at an inpatient level of care. These patients, and patients at lesser levels of care, place their trust in the physicians and nurses who attend them.

The dictum, "First, do no harm," is one that acknowledges the unspoken trust that patients place in their medical caregivers, especially nurses, who are more than ever before patient care managers. From the nurse perspective, the dictum cautions the nursing professional to be alert, and to be attentive to the patient's medical needs with meticulous and detailed nursing notes to support their actions and the decisions they make about the patient's condition and the care delivered by the nursing professional. When the nursing professional abuses substances like alcohol, prescription drugs, or illicit drugs; the nurse is in violation of the dictum, and patients under his or her care are at risk.

Recent literature on studies of nursing professionals has yielded statistics reflecting ten percent of the nursing population has substance abuse problems, and six percent have problems severe enough to interfere with their performance of their duties and responsibilities of patient care (Talbert, 2009). Abuse of prescription medications has been reported as the most prevalent form of substance abuse among nursing professionals (Dunn, 2005). The potential for harm to the patients under the care of an impaired nurse is obvious. Less obvious is the extent to which individuals have been injured, or, worse, patients who might have died as a result of negligent nurses practices as a result of a nurse under the influence of alcohol or drugs.

It becomes immediately clear when researching the topic of substance abuse by nursing professionals that the healthcare industry and the professional nursing organizations and journals are very protective of the profession, and careful of the ways in which they approach this serious social issue in the information that is written and published on the subject (Dunn, 2005, 82(5)). When putting in the keyword "nursing," literally thousands of newspaper articles, professional organizational journal articles, books, and other published materials on nursing. When the keywords are refined with specificity towards substance abuse in the industry, the search engine return diminishes by the thousands. On the Gale search engine, the results went from over a hundred thousand articles on nursing, to just 49 articles when the keyword "nursing" was modified with specificity to "nurse professional substance abuse among nursing professionals." Of the 49 articles returned on the Gale query, only two articles, Trinkoff and Stor (1998) and West (2002) were peer reviewed studies producing quantitative research and statistical data yield.

The yield of results in the search for professional organizational journals and peer reviewed research on the subject is, at best, guarded; and with good cause. The medical practitioner and provider industries are under the microscope in many ways today: liability insurance for practitioners/providers; fraud, abuse, and waste; quality control and infection control; billing for services vs. services and diagnostically related group (DRG) validity; and, in the public spotlight now, national or public healthcare insurance for the millions of uninsured Americans. From each aspect of scrutiny, the provider and practitioner is under pressure to provide quality care, and to deliver the care with integrity and professionalism. Concerns of widespread professional healthcare provider or practitioner substance abuse could jeopardize Medicare, Medicaid, and even some private reimbursements to the provider/clinic/practitioner; and could ostensibly begin a snowball effect of individual and class action law suit activity which might devastate the industry. From these perspectives alone, we can see the serious impact that widespread substance abuse in the nursing profession could have on the industry.

Also, those places where nurses are employed, hospitals, clinics, physicians' offices, as well as the professional oversight organizations, and especially the registered nurses licensing boards all take substance abuse very seriously. State agencies are responsible for licensing nurses (Dunn, 2005). The agencies are responsible for ensuring that licensed nurses possess the skills and abilities to perform their duties (Dunn, 2005). If the nurse is found incompetent, unable to perform his or her duties, or puts the patient at risk, then, ". . . The license is not earned or is suspended or revoked (p. 775). Thirty-nine states have intervention programs and work to help the nurse find an appropriate rehabilitation program, but allow for return to work with review and supervision (p. 775). The issue of licensing, license suspension, or revocation rests with the licensing board (p. 775). Therefore, the subject of substance abuse among nurses is not a subject to be approached carelessly, but approached with an eye towards addressing the issue and resolving problems quickly when they are identified.

This essay will seek to answer the questions:

In what circumstances have patients been found to be harmed or found to have been at risk of harm by nurses with substance abuse problems?

Is the industry minimizing the extent of the problem, and putting patients at risk?

Do nursing professionals have a professional ethical and moral responsibility to report their peers in instances where they suspect or know substance abuse is putting patients at risk; and are they reporting?

Is the response to substance abuse by nurses responsive to patient safety?

What does the nursing industry and nursing professional oversight agencies recommend as the action to be taken when a nurse is found to be abusing alcohol, prescription drugs, or illicit drugs?

This essay is based on a study of existing literature and studies on substance abuse among nursing professionals. The review is to gain an understanding of the information that exists on substance abuse among nursing professionals, and to understand how, when, and where patients are most at risk when under the care of a nurse who is a substance abuser. An annotated literature review provides an at glance look at the materials selected in support of this essay thesis: patients are at risk as a result of nursing professionals who abuse alcohol, prescription drugs, and illicit drugs.

Literature Review

Introduction

The prevalence of substance abuse among nurses is a problem, and has been the source of peer reviewed studies and research in order to gain a better understanding of how to address the problem within the industry. Research from both quantitative and qualitative studies indicate that industry-wide, ten percent of nursing professionals providing patient care suffer from substance abuse, and six percent are impaired by their substance abuse as to cause the patients they attend to be at risk of harm. Patient safety and care must be the primary focus of the medical industry, and when substance abuse poses a risk to patients, action must be taken as quickly as possible to circumvent that problem.

This literature review examines the existing literature to understand how substance abuse is perceived by the professionals in the medical and nursing industries.

Review

Unlike many other web sites, the professional nursing organizations' online journals provide industry information that is written, reviewed, and approved nursing professionals for posting on their professional organization web. The American Nurses Association online Journal (ANAJ) is one such professional organization web site. The web site updates nursing professionals on important events, legislation, and industry-related discussions that the profession might find interesting and useful in their continuing education and work. The web site reiterates on its home page, found online at http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/environmentalhealth.aspx, information, including the nursing dictum, "First, do no harm (2009)." A review of the site shows that it is a professional tool, intended to keep the nursing professional aware and updated on points of interest to a nursing professional. It is, for the lay person, revealing about the hard work and dedication that nursing professionals expend in preparing their selves to become nurses, and to maintain their skills and expertise as they work in their profession. The site is professionally maintained, and the reader of the information gains a sense of the pride and cohesiveness that is shared by nursing industry professionals. It conveys the sense of how nurses are bound to one another by profession, and how they enjoy the support of one another and are supported in their work by their professional counterparts.

This site contains no information directly related to the problem of substance abuse within the profession. The industry related information on the workplace environment is geared towards serving the nursing professional, and especially protecting their rights in the various nursing workplace settings. It begs the question of why, when substance abuse is a problem in the profession, the site offers no resources to the nursing professional as to where they might confidentially turn to for help with substance abuse problems, nor does it encourage the nursing professional who might be suffering such a condition to seek help. This might be as a result of the very public exposure that is inherent in its internet setting, and suggests that perhaps the industry considers substance abuse and guidance for the nursing professional who might seek help to be a condition or problem that is not best addressed on such a public forum level.

One of the professional journals which have published current and pertinent articles on the subject of substance abuse in the nursing profession is the Clinical Journal of Oncology Nursing. An article in this journal by JeanAnne Johnson Talbert (2009) boldly discusses a specific case of a nurse, Tammy, in a hospice setting who puts a patient at risk when she steals the medications of patients under her care (p. 17). In the case discussed, the nurse who follows Tammy notes the level of distress of one particular patient, and, upon examining the patient's chart and medication record, takes action to relieve the patient's distress and pain (p. 17). This action by the nurse who follows Tammy causes the patient to code, and even though the patient recovers, the nurse following Tammy becomes suspicious, and practices good nursing medicine by trying to understand what went wrong with her patient's care (p. 17). The follow-on nurse has actually had a suspicion about Tammy and the patients' medications for some time, but having now experienced a direct patient crisis as a result of what she believes is a case of a nurse stealing patients' pain medications, she reports Tammy (p. 17).

This very important case study, the only one its kind found in the literature, segues to a discussion by the author on substance abuse by nurses (p. 17). The article is well organized, and examines the nurses as substance abusers with criteria for recognizing signs and symptoms of the nurse substance abuser, underlying causes for substance abuse, and, most importantly, the issue of whether or not colleague, fellow nurses, should become involved if they suspect a nurse they work with is abusing substances (p. 17).

The flow of the article is logical, citing current sources in the literature, and even the Drug Enforcement Agency (DEA). It is important because it is the only article of 49 articles that specifically cites a case study involving a patient put at risk because of a nurse's substance abuse. It also demonstrates that while nurses are more likely to abuse prescription medicines, those medicines are not necessarily prescribed for the nurse by a physician, but actually come from the nurse's access to powerful narcotics intended for patient care. It is not only a case of drug abuse, but theft, and patient abuse, because the medications for patients experiencing end of life pain and distress from cancer are being deprived of a quality of life that can only be achieved by administering to their needs with pharmacological interventions. It brings up serious issues about nurses and substance abuse which warrant further studies.

An article found in the American Journal of Public Health, written by Carla L. Stor and Alison M. Trinkoff (1998). This article is one of two found through the search engine query that contains quantitative statistical data as a result of direct research. The statistics support the data cited in other reports as it pertains to the percentages of nurses who have substance abuse problems, and the percentage of nurses, six percent, whose impairment as a result of substance abuse is putting patients in harms way. This study is cited in other articles selected for inclusion here. The data yield is supported by the second article, by Margaret West (2002), which uses the same anonymous mailed survey approach. West, however, employs Donovan's multifactorial model of impairment and the Rogerian Theory of Unitary Human Beings. The Trinkoff and Stor article was available through the search engine only in its abstract form, although the abstract was succinct in the data results of the study. The West article was available as a full-text article.

The West article cites as its weakness the anonymous mailer approach, and we can ostensibly conclude that this weakness would apply to the Trinkoff and Stor study as well. West used a descriptive and co relational and comparative methodology to examine patterns of abuse, and Trinkoff and Stor also looked for co relational patterns, but across nursing specialties. West says the anonymous mailer sample was "one of convenience," and, therefore, "the findings cannot have widespread generalization (p. 193)." Trinkoff and Stor are cited by another of the articles, Dunn (2005).

Summary

The articles selected for this essay have points that support conclusions from one to the next. Each article that addresses the issue of reporting substance abusing nurses who are putting patients at risk, however, that does not happen as often as we might hope. Nurses are trained to be sensitive to social, family, and other conditions which might adversely impact an individual's well being, and, in the face of overwhelming problems in any one of these areas, turns to substance abuse. As might be expected, the industry is protective of their working group, and nurses seldom report one another for substance abuse even when it puts patients at risk (Dunn, 2005, p. 578).

A nurse, such as the one cited in the case study, Tammy, is likely to be disciplined by the licensing board and would lose her license. More recently, however, the industry's protection of nurses and nursing jobs has been reflected by calls for nurses, like other people, to have an opportunity to receive substance abuse treatment and enter a program for support in pursuing and maintaining sobriety (Fletcher, 2004). The problem that arises is that patients are at risk, and as we saw from the case study, it can be life threatening if nurses do not report their colleagues.

Another problem that we find in the literature cited, is that one of the places that a nurse might turn to seek information on getting assistance, the ANAOJ, does not have any information or direction for nurses seeking that kind of help. A nurse with a substance abuse problem who recognizes his or her own need for help, but who is concerned about self-reporting because of the potential consequences, and whose decision making ability might be impaired because of his or her substance abuse, would not find recommendations on an important industry web site.

There are many considerations that must be made when considering the substance abusing nurse, but the nursing dictum, "First, do no harm," must always take precedence. The well being and quality of life of patients in the care of nurses should always be the first and foremost consideration.

Annotated Bibliography

American Nurses Association online Journal; Nursing world;

http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/environmentalhealth.aspx, 2009 -- retrieved October 20, 2009. A professional information web site that updates the nursing industry on news, events, continuing education credits, and other information useful and needed by the nursing profession, falls short in that it has no information whatsoever for the substance abusing nursing professional. This site provides valuable information to the profession, but does not acknowledge the problem in substance abuse in the profession. It is one of the places that a nurse might turn to for information if he or she recognizes that they have a substance abuse problem, and are worried about confidentiality, but they would not find assistance or direction at this site.

Beckstead, Jason W. (2005). Reporting peer wrongdoing in the healthcare profession: the role of incompetence and substance abuse information, International Journal of Nursing Studies, 42(3), 325-332, Gale, Full Text, retrieved October 21, 2009. This is an article that attempts to report and analyze from the nursing professional's perspective. It supports the notion that nurses, as a profession, view substance abuse as a serious condition of the nursing professional. The article, however, goes on to examine the complex ways in which nursing professionals view substance abuse. It contends that their training critical thinking skills acquired during their nursing training makes it a complex issue for them to consider.

Dunn, Deborah (2005). Substance abuse among nurses: Defining the issue, AORN Journal 80(4), 572-595, retrieved 21 October 2009, Gale, Full Text. This article is cited by other articles selected for this essay. It is an independent study focusing on the issues of substance abuse in the nursing profession. It discusses the prevalence of addiction in the nursing profession, signs and symptoms, the adverse effects of failing to report colleagues, and the role of the state boards in following nurses through treatment and recovery. It also looks at how society understands and considers substance abuse in nursing professionals. This article has been cited in the essay as stating that the most prevalent source of substance abuse in the nursing profession is addiction to prescribed medications. It is also cited as the source for specifically stating that nursing professionals practice covering up for their nursing colleagues, and are responsible through this cover up practice for exacerbating the situation. The sources cited in the article are largely up-to-date and current peer reviewed journal articles and studies.

Dunn, Deborah (2005). Substance abuse among nurses: Intercession and intervention (Home Study Program), AORN Journal 82(5), 775-797, Gale, Full Text, retrieved October 19, 2009. This is another installment of the continuing series on substance abuse in the nursing profession by this author. In this article, Dunn focuses closely on the nurse manager's role in counseling and intercession. Reviewing the outcome options, we can easily see the seriousness of the situation. An impaired nurse has a lot to lose, and must literally prove herself reliable before she can return to duty.