The Prevalence of Substance Use Disorder Among Nurses
It is a common misconception that substance use disorder is significantly higher among healthcare professionals due to job stress and easy access to medications. However, recent studies indicate that the rate of alcohol and drug dependency among nurses and physicians is now estimated to be similar to or only slightly higher than that of the general public, ranging from 10% to 15% [3,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.3 “Bettinardi-Angres K, Bologeorges S. Addressing chemically dependent colleagues. J Nurs Reg. 2011;2(2):10-17.”)[5,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.5 “Hudspeth R. Survey of advanced practice registered nurses disciplinary action. Online J Issues Nurs. 2007;12(2):7.”)[6,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.6 “Trinkoff AM, Selby, VL, Han K, et al. The prevalence of substance use and substance use problems in registered nurses: estimates from the Nurse Worklife and Wellness Study. J Nurs Reg. 2022;12(4):P35-P46.”)[9]. This means that a significant portion of the nursing workforce, potentially up to 525,000 nurses in the United States, may be struggling with substance use disorders that could impact their professional performance [12]. The American Nurses Association (ANA) has also reported that approximately 15% of nurses may abuse substances to a degree that could interfere with their ability to practice safely [13,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.13 “Intervention Project for Nurses. IPN Brochure. Available at https://www.ipnfl.org//wp-content/uploads/2022/01/IPN-Brochure-06.24.19.pdf. Last accessed October 22, 2022.”)[17]. Alarmingly, alcohol abuse among nurses is reportedly on the rise, particularly since the onset of the COVID-19 pandemic [4]. Given that nurses constitute the largest segment of healthcare workers, substance-related impairment within this profession poses a significant healthcare challenge [9].
Types of Substances Abused by Nurses
While alcohol remains the most commonly abused substance among nurses, prescription drug misuse is a significant concern within the profession. Studies, such as the Nurse Worklife and Wellness Study, have revealed that past-year illicit drug use among nurses was 5.7%, while prescription drug misuse was notably higher at 9.9% [6]. Interestingly, the use of street-type drugs like cocaine and cannabis is found to be lower in nurses compared to the general population [5].
The higher rate of prescription drug abuse among nurses can be attributed to factors such as easier access to medications in the workplace, familiarity with drug dosages and effects, and a sense of comfort in experimenting with drugs they commonly administer to patients [6]. This phenomenon, known as “pharmacologic optimism,” stems from a deeply ingrained belief in the healing power of pharmaceutical drugs and a minimization of their potential negative effects – an idea often instilled early in nursing careers [9]. Besides alcohol and prescription drugs, other substances frequently abused by nurses include amphetamines, opioids, sedatives, tranquilizers, and inhalants [6,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.6 “Trinkoff AM, Selby, VL, Han K, et al. The prevalence of substance use and substance use problems in registered nurses: estimates from the Nurse Worklife and Wellness Study. J Nurs Reg. 2022;12(4):P35-P46.”)[9].
Unique Risk Factors for Substance Use Disorder in Nurses
While nurses share common risk factors for substance abuse with the general population, several factors are particularly unique to the nursing profession [9,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.9 “National Council of State Boards of Nursing. Nursing Regulation: Substance Use Disorder in Nursing. Available at https://www.ncsbn.org/nursing-regulation/practice/substance-use-disorder/substance-use-in-nursing.page. Last accessed October 22, 2022.”)[15]:
- Pharmacologic Optimism: As mentioned earlier, a positive attitude towards drugs and drug use, or “pharmacologic optimism,” can be a significant risk factor.
- Easy Access to Medications: The healthcare environment provides relatively easy access to a wide range of pharmaceutical drugs.
- Relaxed Prescribing Practices: Facilities with relaxed physician prescribing practices can inadvertently contribute to drug diversion and misuse.
- Lack of Pharmaceutical Controls: Inadequate controls over drug dispensing and administration within a facility can increase the risk of diversion.
- Insufficient Education: Limited or no education regarding substance use disorders, their signs, and consequences can hinder prevention and early intervention efforts.
- Enabling Behaviors: Peers and managers who enable substance abuse by ignoring or covering up for colleagues’ impairment contribute to the problem.
- Role Strain: The demanding and stressful nature of nursing, including long hours, emotional toll, and high-pressure situations, can contribute to substance use as a coping mechanism.
Furthermore, gender plays a role in substance abuse patterns among nurses. Male nurses are statistically more likely to abuse substances and are over-represented in treatment programs [9]. Despite this, the majority of nurses with substance use disorders are women due to their overwhelming representation in the nursing profession (approximately 90% of RNs and LPNs are female in the United States) [9,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.9 “National Council of State Boards of Nursing. Nursing Regulation: Substance Use Disorder in Nursing. Available at https://www.ncsbn.org/nursing-regulation/practice/substance-use-disorder/substance-use-in-nursing.page. Last accessed October 22, 2022.”)[12]. Research suggests that addiction may manifest differently in men and women, with men often experiencing a more acute course and seeking help sooner, while women’s addiction tends to be more prolonged with a greater impact on mental and physical health, often delaying treatment as they seek help for related symptoms like depression or anxiety [9].
Identifying Impaired Practice in the Workplace
Recognizing the signs and symptoms of impaired practice is crucial for maintaining patient safety and supporting colleagues in need. It’s important to differentiate between a pattern of impairment and isolated incidents potentially caused by job stress. Studies indicate that many nurses struggle to accurately identify impairment due to limited education on recognizing these signs in a professional setting [3,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.3 “Bettinardi-Angres K, Bologeorges S. Addressing chemically dependent colleagues. J Nurs Reg. 2011;2(2):10-17.”)[18]. This challenge is further complicated by the fact that experienced healthcare professionals can sometimes maintain a high level of functionality even while under the influence of substances.
Impaired nursing practice is NOT defined as isolated incidents caused by job stress. It is a pattern of behaviors that indicate a nurse’s inability to perform their professional duties safely and effectively due to substance use or other conditions.
Failing to recognize impairment or believing that reporting is unnecessary because a colleague appears to be functioning normally can inadvertently enable substance abuse by preventing timely intervention [3]. Conversely, nurses who are knowledgeable and confident in identifying impairment are more likely to take appropriate action, confront colleagues (in a supportive manner as per protocol), and report their concerns according to employer guidelines.
Signs of Potential Drug Diversion
Several behavioral and circumstantial signs may indicate that a healthcare professional is diverting drugs for personal use [7,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.7 “Intervention Project for Nurses. Employer Information. Available at https://ipnfl.org/employer-information. Last accessed October 26, 2022.”)[8,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.8 “American Association of Nurse Anesthetists. Signs and Behaviors of Impaired Colleagues. Available at https://www.aana.com/practice/health-and-wellness-peer-assistance/About-AANA-Peer-Assistance/substance-use-disorder-workplace-resources/signs-and-behavior-of-impaired-colleagues. Last accessed October 26, 2022.”)[22]:
- Volunteering for Pain Medication Administration: Frequently volunteering to work with patients requiring regular or large doses of pain medication or consistently volunteering to be the medication administrator.
- Excessive Controlled Drug Sign-Outs: Often signing out more controlled substances than colleagues.
- Lack of Co-signatures: Frequently failing to obtain required co-signatures for medication administration or waste.
- Frequent Medication Spills or Waste Reports: Frequently reporting medication spills or other forms of drug waste.
- Discrepancies in Medication Records: Reports reflecting unusually high pain medication use by patients or discrepancies in end-of-shift medication counts.
- Tampering with Medications: Evidence of tampering with medication vials, containers, or medication counts.
- Secrecy Around Narcotics: Waiting until alone to access narcotics cabinets or disappearing after opening them.
- Patient Pain Complaints: An increase in patient complaints of unrelieved pain.
- Defensiveness: Showing defensiveness when questioned about medication errors.
- Unusual Work Habits: Consistently arriving early and staying late.
The Importance of Reporting Impaired Colleagues and Mandatory Reporting Laws
Reporting a colleague suspected of impairment can be a challenging decision for nurses. However, it is a critical ethical and legal responsibility to ensure patient safety and provide colleagues with the help they need. Florida law, for example, mandates that Board-licensed nurses report known workplace impairment, whether it’s an acute situation or a growing suspicion [3].
It is FALSE that experienced, older nurses are more likely to report impairment because they have witnessed negative effects. In fact, experienced nurses ARE MORE likely to report impairment. Younger and less experienced nurses are often less likely to report, potentially due to fear or uncertainty [3]. Common reasons for failing to report include fear of being a “tattle-tale,” fear of retaliation, concern about jeopardizing a colleague’s job, lack of confidence in one’s observations, and believing someone else will handle the situation [1,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.1 “National Council of State Boards of Nursing. Nursing Regulation: Discipline. Available at https://www.ncsbn.org/alternative-to-discipline. Last accessed October 26, 2022.”)[3].
Despite these concerns, the nursing profession prioritizes patient safety above all else. Failing to report suspected impairment is a failure to act in accordance with this core principle and neglects the opportunity to help a colleague in need of recovery [3].
Reporting Procedures and the Role of Intervention Programs
Nurses should be well-informed about their organization’s policies and procedures for reporting suspected employee substance abuse and available assistance programs [16]. Understanding the resources available, including employee assistance programs or alternative-to-discipline programs, can empower nurses to report impairment more readily.
In Florida, the Intervention Project for Nurses (IPN) was established to serve as a central point for reporting, treatment facilitation, and monitoring of impaired nurses [20]. Reporting suspected impaired practice to Florida’s IPN DOES fulfill the mandatory reporting obligation. Florida nurses are required to report to either the IPN or the Florida Department of Health, both of which satisfy the legal requirement [21]. These programs prioritize recovery and rehabilitation, aiming to support nurses in returning to safe practice [3].
Ethical Guidelines for Intervention
The American Nurses Association (ANA) Code of Ethics does NOT recommend confronting potentially impaired colleagues as the initial course of action before notifying a supervisor. Past recommendations to directly confront impaired individuals have been deemed unrealistic and are no longer endorsed [2,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.2 “American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2015.”)[3,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.3 “Bettinardi-Angres K, Bologeorges S. Addressing chemically dependent colleagues. J Nurs Reg. 2011;2(2):10-17.”)[16,](/coursecontent.php?courseid=2477&works=true#bibl.workscited.16 “Thomas CM, Siela D. The Impaired Nurse: Would You Know What to Do If You Suspected Substance Abuse? Available at https://www.americannursetoday.com/the-impaired-nurse-would-you-know-what-to-do-if-you-suspected-substance-abuse. Last accessed October 26, 2022.”)[22].
The current ANA Code of Ethics emphasizes that a nurse’s primary duty is to protect patients and ensure the impaired individual receives assistance. This process should begin with consulting supervisory personnel, followed by approaching the individual in a clear and supportive manner and facilitating access to appropriate resources [2]. Nurses are also expected to adhere to organizational policies, professional guidelines, and relevant laws when assisting colleagues who may be impaired due to various factors, including substance abuse [2].
Timely Intervention and Treatment Programs
When a nurse is reported for suspected impairment, timely intervention is critical. It is TRUE that intervention typically occurs within one to three days after a report is made to the IPN or the Department of Health [1]. This rapid response is a significant advantage compared to traditional disciplinary processes, which can take months to resolve [1]. Self-reporting nurses receive immediate intake and evaluation.
The IPN program in Florida aims to ensure public safety by closely monitoring nurses who are unsafe to practice due to substance use or other conditions [13]. Key objectives of such programs include:
- Immediate Withdrawal from Practice: Requiring nurses to immediately cease practice until their ability to safely return is assured.
- Early Intervention: Facilitating prompt intervention to reduce the time between problem recognition and entry into a recovery program.
- Therapeutic Rehabilitation: Providing a non-punitive, confidential rehabilitation process.
- Professional Retention: Offering an opportunity for nurses to remain in the nursing profession.
- Cost-Effective Alternative: Presenting a more cost-effective approach compared to traditional disciplinary measures.
- Resource Network: Developing a statewide network for referring nurses to appropriate services.
- Confidential Consultation: Offering confidential consultations for nurse managers.
By understanding the scope of substance use disorder in nursing, recognizing risk factors and signs of impairment, and adhering to ethical and legal reporting guidelines, nurses can play a vital role in protecting patients and supporting their colleagues on the path to recovery and safe practice.
