Substance abuse among nurses and patient safety risks

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.

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.

Fletcher, Carol E. (2004). Experience with peer assistance for impaired nurses in Michigan (Profession and Society -- Abstract) (nurses with substance addiction, Journal of Nursing Scholarship, 36(1), 92-94, Gale, Full Text, retrieved October 10, 2009. This article is a study of working with impaired nurses in the state of Michigan. The strength impaired nurses gain from working through addiction with their peers is an invaluable tool in their treatment and recovery. The nursing professionals are a protective and close group as a profession, and were appreciative of the seriousness expressed about their impairment from their peers, and were better able to identify important issues. It also motivated advocacy in the recovering nurses towards legislation that would help the profession meet the needs of their recovering colleagues in the profession. Issues were identified in this article that impacted self-reporting and the problems confronting the nurse who wanted to seek help, but were fearful of the strict repercussions of being identified as a substance abuser.

Griffith, Jane (1999). Substance Abuse Disorders in Nurses, Nursing Forum, 34(4), 19, Gale, Full Text, retrieved October 13, 2009. This article examines the psychosocial, psychological, and neurobiologic theories on substance abuse in each of these areas of impact. Once understanding the impact of impairment, it becomes increasingly clear that impaired nurses are indeed a threat to their patients. Also, the article leads the reader to the conclusion that there is probably vast under reporting of nurses suffering impairment. It examines closely diversion and treatment, and agency oversight during treatment and post treatment.

Ledema, Rick, Merrick, Thomas, Rajbhandari, Dorrilyn, Gordo, Allen, Stirling, Anne, and Herkes, Robert (2009). Viewing the taken-for-granted from under a different aspect: a video-based method in the pursuit of patient safety, International Journal of Multiple Research Approches, 3(3), 290-302, retrieved October 20, 2009, Gale, Full Text, retrieved October 19, 2009. This article is advocating patient safety, and supports using technology to monitor and evaluate nursing care. It recognizes as the most dangerous time in patient care as the hand-over, either changing shifts, or from different ancillary and departmental services. The article holds that the use of technology helps put organizational and nursing goals in perspective with the focus on patient care and the quality of care rendered. The article utilizes a combination of up-to-date sources, and some sources that are very outdated, going back to the 1960s.

Talbert, Johnson JeanAnne (2009). Substance Abuse Among Nurses. Clinical Journal of Oncology Nursing, 13(1), 17, retrieved October 13, 2009 from Gale, Full Text. This article is a quantitative study on the subject of substance abuse among nursing professionals. It focuses on identifying the signs and symptoms of the nurse substance abuser, and explores the psychological factors underlying the nursing professional's substance abuse. The article supports making it easier for the nurse addict to seek help and to establish a support system for recovery without being severely penalized abusing substances.

Thompson, Noreen, Handley, Sandra M., and Uhing-Nguyen, Sheila (1997). Substance abuse in nursing: forming policies, Nursing Management 28(n2), 38-42, retrieved Gale, Abstract. This article is a staunch advocate of forming policies that include: intervention, prevention, impaired practice identification, evaluation, treatment, and reentry to nursing. It does not support revoking a nurse's license, but contends that with the proper treatment and support that nursing professionals are strong candidates to overcome their addiction and be reliable nurses.

Trinkoff, Allison M., and Stor, (1998). Substance Abuse Among Nurses: Differences between specialties, American Journal of Public Health, 88n, 581-585. Retrieved October 13, 2009 from Gale, Full Text. Trinkoff and Stor's quantitative research, first published in 1998, is one of the few articles which provide data from a study conducted by the authors, and is cited by others on the subject of substance abuse in the nursing profession. The article readily acknowledges that substance abuse is a problem in the nursing profession, and one that has existed for 150 years. The article addresses the issue in frank and forthright manner, and does not hold nurses out as special people as do some of the other articles. It also considers honestly and without bias the conditions under which people can recognize signs of substance abuse in nurses, but it makes no excuses and holds that colleagues should report nurses if they find reasonable suspicion to believe that their colleagues are abusing substances while caring for patients.

White, Lois (2004). Foundations of Nursing, Thomas Delmar Learning, Clinton Park: New York. This book contains a section on impaired nurses, and is strongly from the public perspective. It closely reviews the steps that nurses should take in documenting their peers when they suspect that the peer is abusing substances. It closely reviews the ethical responsibilities by which the nurse professional is bound in taking action to protect patients and to report peer substance abuse.