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Impaired Nurses
Kelly Geraghty
Ferris State University
Abstract
The rate of substance abuse among nurses is alarming. This paper contains information on the impaired nurse and reasons they may turn to substance abuse. It also elaborates on theory related to this topic. This includes nursing and non- nursing theory. An analysis of the impaired nurse is included. The inferences and points of view of the nurse and patient regarding substance use will be included. The Quality and Safety and American Nurses Association standards that apply to the impaired nurse will be included. Finally there will be a summary of the overall impaired nurse.
Impaired Nurses
According to Cadiz, Truxillo, and O’Neil (2012) in the United States substance abuse continues to be a serious health care concern in the United States and more than 22 million people misuse drugs or alcohol. This not only affects the individual but also family, friends, coworkers and society. Six to eight percent of nurses are substance abusers and this number is about the same as the general population; however there are occupational hazards that may make the nurse turn to substance abuse (Cadz etal., 2012). Some examples of these may include lack of education on addiction, assess to medications, a high stress environment (Cadz etal., 2012).
When a nurse is impaired they may become dysfunctional and unable to provide safe quality care. Although addiction is considered a disease the nurse still remains responsible for any actions made while working (Thomas & Siela, 2011). We need to know the signs and symptoms of a coworker who may be abusing substances. Some of these signs may be being ungroomed, tired, suddenly late often, defensive, and having mood changes. There are many signs and symptoms and we have a responsibility as nurses to protect our patients.
According to Thomas and Siela (2011), it is important to inform a manager if you are suspicious that a coworker may be abusing substances. You should document and report any changes you see in your coworker’s behavior (Thomas & Siela, 2011). This is an ethical and moral duty of a nurse. Getting the coworker the help they need is important. “Treatment can be effective in reducing substance use and improve health, social, and occupational wellbeing” (Thomas & Siela, 2011, p. 3).
There are various points of view on this issue including the view of the impaired nurse, coworkers of the impaired nurse, and the patients. The impaired nurse probably does not even realize that their abuse is affecting the people around them. They may just keep going to work and acting like everything is fine. Some of the points of view of the coworkers may be tired of picking up the slack for their impaired coworker, scared to report coworker to supervisors, feel responsible for the errors the coworkers make. Some patient points of view may include they feel they deserve safe quality care, lack of respect for the impaired nurse, the patient may ask for a different nurse, or may direct family and friends to other places for treatment.
Theory
Two theories that are related to the impaired nurse are the theories by Dorthea Orem and Albert Bandura. Dorethea Orem’s is a Nursing Theory. Albert Bandura developed the Social Learning Theory. Although one is a nursing theory and one a non-nursing theory, they both apply to the impaired nurse.
Dorthea Orem’s Self-Care Deficit Theory
Dorthea Orem’s Self-Care Deficit Nursing Theory was composed of three theories. These included self-care, self-care deficit, and nursing systems. According to Nursing Theory (2011) some major assumptions of this theory included people should be responsible for their care and the care of their family members, people are individuals, nursing is the action of between two or more people, and to promote self-care a knowledge of potential health problems is needed. This theory applies to the impaired nurse because in order to provide quality and safe care they need to start by caring for themselves.
According to Nursing Theory (2011) self-care is the activities that a person performs to maintain their life, health and well-being. This theory also includes therapeutic self-care demand and self-care requites which include universal, developmental, and health deviation self-care requisites.
Universal self-care requisites are the activities of daily living and my include maintaining the intake of air, food and water, care of elimination process, balance between rest and socializing, preventing hazards to human life, and promoting functioning of the human (Nursing Theory, 2011). Developmental self-care requisites usually have an association with development and come from an associated event (Nursing Theory, 2011). The final requisite is health deviation self-care requisites. This may include seeking medical help, being aware of medical conditions, carrying out medical orders, learning to live with a condition, and accepting oneself in a particular state of health (Nursing Theory, 2011). This may mean that the nurse who is abusing substances is not thinking about their well being. They are suffering from an addiction that is not allowing them to perform as expected on their own behalf or the behalf of their patients. They are conditioned to feel a certain way and will abuse substances to feel this way.
Self-care deficit is when nursing is needed. There are five methods of helping that are identified in this theory including “acting for and doing for others; guiding others; supporting another; providing an environment promoting personal development in relation” (Nursing Theory, 2011, para 7). The impaired nurse may be in denial they have a problem. They may lie and turn away help that is being offered to them. They are unable to support their coworkers and patients because they are impaired.
The final part of this theory is nursing systems. This “describes how the patient's self-care needs will be met by the nurse, the patient, or by both” (Nursing Theory, 2011, para 8). This part of the theory is related to the care the impaired nurse takes of them as well as the care the impaired nurse gives their patients. The impaired nurse may be have an untidy appearance and not very helpful to their coworkers. The patients of the impaired nurse may complain they are not meeting their needs.
Social Learning Theory
The non-nursing theory that can be applied to the impaired nurse is Albert Bandura’s Social Learning Theory. According to Cherry (2012) this theory contains a social element that people can learn through watching the behaviors of others. This theory had three concepts. The first was learning can be done through observation (Cherry, 2012). A person may turn to substance abuse if they have been exposed to this routinely while growing up. An impaired nurse that is abusing may have watched their mother or father and be repeating this pattern.
According to Cherry (2012) the second concept is mental states are important to learning. The impaired nurse may refuse help due to pride. This may contribute to the denial that is occurring. This nurse may be failing to get work done but refuse to listen to coworkers who try to help.
The third concept is learning may not lead to a change in behavior (Cherry, 2012). There are steps that a person takes for a change to have occurred. These include attention, retention, reproduction, and motivation (Cherry, 2012). The impaired nurse would have need to be exposed to all of these factors to have the behavior change needed to become a substance abuser.
Assessment of Internal Environment
There are many reasons that a nurse may turn to substance abuse. Many nurses fear punishment and discipline and this may cause them to avoid seeking help for their addiction or may keep a colleague from reporting their coworker. The odds that a friend will not report their coworker are 5 to 1(Monroe & Kenega, 2010). We need to intervene as soon as we notice that our peer is displaying actions that are not ordinary for them.
According to Thomas and Siela (2011) some signs and symptoms of an impaired nurse may include unexplained absences from their unit, mood changes, and discrepancies in the medication records for their patients, decreased quality of care, frequent lying, and decrease in grooming. These signs may be right in front of our face but we are focusing on our patient care and may not notice the signs of substance abuse that our coworker is displaying. Increasing our awareness of what to watch for in the impaired nurse can help use recognize and try to find help for this person early.
Root Cause Analysis
The nurse may turn to substance abuse to avoid conflicts that may be going on in her life. According to Bissonnette and Doerr (2010) causes of the impaired nurse may be that the nurse has drugs available and the opportunity to use these. An example of this is the access a nurse has to the pixis. Many nurses are known to self treat. This person may believe that drugs are effective because they feel they have the knowledge of the drug’s effects and should use them to feel well (Bissonnette & Doerr, 2010). The nurse may believe that because they have knowledge on the drugs that they will not become addicted and finally the nurse may have a genetic disposition to addiction (Bissonnette & Doerr, 2010). They may have inherited the tendency from their parents. Each individual impaired nurse may have turned to substance abuse because on one or more of these causes.
According to Maher-Brisen (2007) there are many workplace resources for nurses with substance abuse issues. These may include employee health services and human resources. They can also seek support from their managers and peers or use community services such as alcoholics anonymous or narcotics anonymous. Along with workplace resources there are policies and organizations that can help the impaired nurse. These may include the Alternate to Discipline (ATD) policy, The American Disability Act (ADA), and the Equal Opportunity Employment Commission.
Alternate to Discipline Policy
The ATD policy was developed to protect the impaired nurse. According to Monroe and Kenaga (2010) this was divided into four areas. The first area was by advocating for rehabilitation over punitive discipline we could provide assistance to our colleague. The nurse could return to work under this area. The second area was the preferred method to regulatory intervention and professional discipline was self regulation. If the nurse is reported to the Office of the General Inspector they may be unable to get liability insurance. The third area is to prevent below standard nursing practice then public health and welfare should be protected and the final area reported was the pursuit of policy and action that would promote wellness and safety in the workplace (Monroe & Kenaga, 2010). This should be done through collective bargaining and advocacy in the workplace. Addicted nurses should be treated with respect and discipline only used if the nurse is unable to be rehabilitated.
American Disability Association
The ADA provides guidelines for an employer to determine whether an employee who has a substance abuse problem falls under having a disability. According to Menendez (2010) the ADA defines disability as having a physical or mental impairment that affects or limits one or more life activities, having a record of this impairment, or being know to have this impairment. This leads to the conclusion that nurse managers need to ensure their employees give safe and competent care while being responsible to uphold civil rights for their employees.
Menendez (2010) states the ADA allows a nurse that has a substance abuse disorder to be legally terminated if they pose a risk to the safety of their patients. The factors to be considered for termination are the threat the impaired nurse poses, the severity and nature of the potential harm, if it is likely that harm can occur, and if there is imminence of potential harm. The patient needs to be protected even if this means the impaired nurse is terminated.
Equal Opportunity Employment Commission
Menendez (2010) states that the Equal Opportunity Employment Commission considers a nurse having a disability if the abuse substantially limits major life activity or it limited activities in the past. The nurse that is protected under these rules is required to operate under employee rules including not being under the influence of alcohol at work (Menendez, 2010). Impaired nurses should be direct toward resources to help overcome this addiction.
Inferences/ Implications/ Consequences
There are many support systems available to help the drug addicted nurse. We need to be aware of our surroundings and report any behavior that is suspicious of our coworkers. We have a duty to ensure the safety of our patients. If nurses are continued to be allowed to abuse substances we will continue to see the effects in the care these nurses provide their patients.
According to Harling and Turner (2012) social, cultural, and individual influences have an effect on the nurse and the way they practice. The way a nurse is exposed to the issue of the impaired nurse during their training can have a direct influence on their attitudes of their abusing coworkers. Stereotypes can also affect the views of coworkers who may have a substance abuse problem. If a nurse has not received proper training on this issue then their lack of knowledge may also lead them to ignore the signs their impaired coworker is exhibiting.
Recommendations for Quality and Safety Improvements
Quality and Safety Education for Nurses
The goal of the Quality and Safety Education for Nurses (QSEN) is to help prepare future nurses with the knowledge, skills, and attitudes they need to improve the quality and safety in the healthcare systems in which they are employed (QSEN, 2012). The two QSEN competencies that related to the impaired nurse are Teamwork and Collaboration and Safety.
According to QSEN (2012) team work and collaboration is to “function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (QSEN, 2012, para 4). This competency could apply to the impaired nurse because the nurse needs to be able to function competently in the scope of their practice as a member of the health care team. If this nurse is impaired this will likely effect how this nurse functions alongside their coworkers. The impaired nurse may leave tasks unfinished, leaving their coworkers with this extra work. They also may lack the decision making skills needed because their judgment is impaired. It is important to education staff members to report suspicions. Nurses have an obligation to protect the patient population.
The second QSEN competency that applies to the impaired nurse is safety. QSEN defines this as “minimizes risk of harm to patients and providers through both system effectiveness and individual performance” (QSEN, 2012, para 7). The safety competency applies to the impaired nurse by their inability to reduce the risk of harm to themselves and others if they are impaired. To avoid errors in the workplace nurses need to confront this coworker when signs of unsafe practice are being shown. If a nurse feels their coworker is giving the wrong medication, make this nurse stop and double check this medication with another nurse. Every nurse is responsible for the safety of all patients.
ANA Standards
“The American Nurses Association has declared its commitment to increasing nurse awareness of the potential health and patient safety risks associated with untreated substance use and mental disorders” (Cadiz, Truxillo, & O’Neill, 2012, p. 135). There are several American Nurses Association (ANA) standards to apply to the impaired nurse.
The first ANA standard that applies to the impaired nurse is Standard 7 Ethnics. According to the ANA (2010) the nurse will take action when they recognize illegal, unethical, or inappropriate behavior or situation that can jeopardize the healthcare consumer and speak up when appropriate to question health care practice for quality and safety improvement. The impaired nurse may be jeopardizing patient safety and it is the coworker’s responsibility to report any unsafe practices to management. The nurse needs to step in when they see care that is unsafe and provide the recommended care.
The second ANA standard that applies to the impaired nurse is Standard 10 Quality and Practice. According to the ANA (2010) nurses need to identify problems that occur in their daily work routines in order to fix process inefficiencies. The nurse that is coming to work impaired or tired from being impaired will not provide quality and safe care. These nurses need to be directed to proper resources so that help can be obtained for their addiction. There are many resources available to the impaired nurse. Nurses need to help direct coworkers even if this means this coworker may lose their job.
The third ANA standard that applies to the impaired nurse is Standard 13 Collaboration. According to the ANA (2010) the nurse needs to collaborate with the patient, family and other members of the community and adhere to standards that create a trusting, respectful, and cooperative work environment. Nurses need to provide care that has been collaborated with a multidisciplinary team. If the nurse is impaired they may only think of their needs and not the needs of the patients. We need to make sure all of the patients needs are met. Stepping in and assisting the impaired nurse can help accomplish this goal.
Summary
The impaired nurse may be working in any of our places of work. We need to be familiar with the signs and symptoms. It is our responsibility to report any suspected abuse to our supervisors. Patients rely on their nurses to provide care that is safe and of quality. There are many resources that are offered to help the impaired nurse. Often they are unaware they have a problem and may need guidance to obtain the help that they need.
References
ANA. (2010). Nursing scope and standards of practice (2nd ed). Maryland, MD: .
Bissonnette, T., & Doerr, J. (2010) Impaired nursing practice and the law in Michigan. Michigan Nurse, 83(5), 1-8, Retrieved from http?//files/files/Nursing%20Practice/CEModule_ImpairedPractice.pd f
Cadiz, D., Truxillo, D., & O’Neill, C. (2012). Evaluation of a training program for nurses supervisors who monitor nurses in an alternative-to-discipline program. Advances in Nursing Science, 35(2), 135-144. Doi:10.1097/ANS.0b013e31824fe6e0.
Cherry, K. (2012) Social learning: an overview of Bandura’s social learning theory. Retrieved from
Harling, M. R., & Turner, W. (2012). Student nurses attitudes to illicit drugs: a grounded theory
study. Nurse Education Today, 32, 235-240. Doi:10.1016/j.nedt.2011.05.002.
Maher-Brisen, P. (2007). Addiction: an occupational hazard in nursing. American Journal of
Nursing, 107(8), 78-79.
Monroe, T., & Kenaga, H. (2010). Don’t ask don’t tell: substance abuse and addiction among
nurses. Journal of Clinical Nursing, 20, 504-509. Doi: 10.1111/j.1365-
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Menenzez, J. B. (2010). Americans with disabilities act-related considerations when an alcoholic
nurse is your employee. Jona’s Healthcare Law, Ethics, and Regulation, 12(1), 21-24.
Nursing Theory. (2011). Orem’s self-care deficit theory. Retrieved from http:/nursing-
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Thomas, C. M., & Siela, D. (2011). The impaired nurse: would you know what to do if you
suspected abuse? American Nurse Today, 6(8). Retrieved from
QSEN. (2012). Competency KSA’s. Retrieved from
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