“Why didn’t I know?” the reality of impaired nurses
When you think of a nurse addict, what do you imagine? Maybe you picture a lower functioning, incompetent individual who frequently calls out sick? You may think that you know about addiction and can detect an addict a mile away. You may say to yourself that you would never become addicted because you know better. You may be surprised to learn that the profile of an impaired nurse is contrary to what many believe. If you work with 10 nurses, one of those nurses is struggling with or is in recovery from the disease of addiction without a doubt.
For nurses, addiction is the most frequent cause of practicing while impaired. Many nurse addicts are not identified as impaired and continue to practice, placing patients and themselves at great risk. Impaired nursing is a serious public health crisis. Connecticut does not have ‘a formalized, structured monitoring program to deal with this crisis, a program that 37 other states currently have. We can no longer afford to ignore, ostracize, or punish our fellow nurses who have this progressive and fatal disease. We need to learn more about addiction as a disease, what recovery really is, and be advocates for those of us affected.
We will sift through some of the myths and explore the facts of addictive disease and chemical dependency. When we refer to “addiction” and “addicts” in this article, we are referring to alcoholism and alcoholics as well. The terms are interchangeable. The only distinction is the drug of choice.
In general, it is estimated that 10% of the population has the disease of addiction. Nurses are equally as susceptible to alcoholism, but are at a higher risk for drug addiction. Some studies have indicated that it may be 50% higher than the general population. There are 60,000 nurses in Connecticut, 45,000 in active practice. Applying these statistics to the nursing community in our state means that 4,500-6,000 nurses are at risk for this disease.
Addiction is a disease. A simple definition of a disease is “anything that interferes with the ability of a human to function normally.”
Addiction is the use of mood-altering substances manifested by a loss of control, a compulsion or craving, the need to use in spite of the risk and adverse consequences, and interference with the functioning in the family and society. It is a brain disease that develops over time as a result of initial voluntary behavior of using drugs and alcohol. These long-lasting brain changes are responsible for the distortions in cognitive and emotional functioning that characterize addicts. Addiction is a belief in the efficacy of drugs (especially true for nurses). Denial of a problem is the hallmark of addiction. The addict needs to abstain from all mood-altering substances for a permanent recovery.
Compulsions overwhelm all other motivations.
Addiction as a disease can be described in the following ways:
PRIMARY: It is a disease in its own right, not a symptom of another disease. It causes its own signs and symptoms.
ACUTE: Addicts frequently display symptoms, such as overdoses and acute withdrawal, or accidents that necessitate the need for emergency care.
CHRONIC: It is permanent. It requires changes of the individual over the course of their lifetime. it requires a commitment to adherence of a daily regimen to maintain optimum health, much like diabetes.
PROGRESSIVE AND PREDICTABLE:
Addiction only gets worse without treatment affecting more systems with increasing severity. Even if an addict is clean and sober for many years, the disease itself is still progressing. Symptoms that haven’t been observed for many years return as soon as the addict relapses. They pick up right where they left off; no matter how much time has gone by. The illness is well under way before the victim is aware that they have it. In other words, they have no idea at what point they turned from a “cucumber to a pickle.”
INCURABLE AND IRREVERSIBLE: There are no effective cures. There is only management of the symptoms to prevent an acute episode. The addict can return to a normal life only as long as the drinking,or drug use stops completely.
FATAL: Death may come as the result of an acute event like an overdose or an accident or by the chronic effects of the disease over time. With alcohol in particular, no system is immune from the effects of chronic consumption.
Addiction effects the four spheres that make us human-physical, psychological, social and spiritual. No sphere is resistant, immune, or in any way unaffected.
Addiction can also be defined as a disease because it responds to treatment.
There is much confusion about the concept of addiction, which comes from trying to make a distinction as to whether specific drugs are physically or psychologically addicting. This historically revolves around whether physical withdrawal symptoms occur when abstinent from that substance. The physical withdrawal symptoms of opiate and alcohol addiction can be managed with medication in a safe setting. The most dangerous and addictive drugs do not produce physical withdrawal symptoms. They include:
Neurobiology of Addiction
Why do certain substances have the power to make us feel good? Using drugs repeatedly over time changes the brain structure and function in fundamental and long-lasting ways that can persist long after the individual stops using. These changes in structure and function occur due to neuroadaptive changes and new memory connections in various circuits of the brain. Addiction is the hijacking of the autonomic nervous system-the primary learning system, the pleasure reward cycle. These changes are due to neurotransmitters. Neurotransmitters, substances that ferry messages from one part of the brain to another, underlie every thought, every emotion, every memory, and all of our learning. When someone is exposed to alcohol or drugs that produce feelings of euphoria, this autonomic learning takes over.
It is now believed that the neurotransmitter dopamine is the master molecule of addiction. Addictive substances enhance the action of dopamine, which fools the brain into thinking that drugs are as beneficial as nectar to the bee, thus hijacking the reward system that dates back millions of years. Each time a neurotransmitter like dopamine floods a synapse, the circuits that trigger thoughts and motivate actions are also etched into the brain. Drugs stimulate dopamine production-assaulting receptor sites, making them respond defensively, causing a dopamine deficit. So, while addicts initially take drugs to feel high, they end up taking drugs just to feel normal as a result of this dopamine deficit.
Development of Addiction
As with any other chronic disease, anyone can develop the disease of addiction. The signs and symptoms are not readily apparent in the early stages. There is a genetic element that predisposes an individual to this disease, but this genetic loading does not guarantee the development of addiction. This disease is predictable, but it cannot be predicted; anyone who is exposed to mind altering substances is at risk for this disease.
Signs and Symptoms
* Slurred speech
* Watery eyes
* Constricted/ dilated pupils
* Unsteady gait
* Runny nose
* Weight loss/gain * change in personal grooming
* Mood alterations/swings
* Inappropriate laughter
* Impaired concentration
* Hiding track marks w/ clothing
* ^ relationship problems
* ^ c/o physical pain
* Diligent/extra shifts-This is a quality any nurse manager would love in an employee. You may think the nurse would use more sick time, but work is where the drug supply is.
* Frequent requests for work schedule/ assignment alterations-^ drug access
* Difficulty completing assignments in timely manner
* Sloppy documentation and/or unacceptable performance
Appearance on unit on days off
* Frequent trips to bathroom
* Brief unexplained absences from unit
* Medication errors * Isolation from co-workers
* Mood changes after mealtime
* Frequent reports of poor pain relief by patients
* Obsession with: Narcotic cabinet or Pyxis, volunteering to medicate co-workers patients, patient’s pain control
1. Large amounts of wasted narcotics-attributable to one specific nurse
2. Many narcotic sign-outs by a particular nurse
3. Significant increases in stock replacements
4. Discrepancies between narcotic record and patient record
5. Discrepancies between patient reported pain relief and patient record
6. Alterations of verbal or telephone orders for controlled substances
7. Frequent incorrect narcotic counts
8. Evidence of vial tampering
9. Using Pyxis code of another nurse
So, what happens now? The addict is unable to stop taking drugs despite the consequences. Remember-addiction is a powerful brain disease expressed in the form of compulsive behavior, a medical condition that demands formal treatment. Recovery is an ongoing process requiring abstinence from mood-altering substances and changing one’s thinking patterns, attitudes, behaviors and lifestyle. As in any building process, recovery must begin with a strong foundation-a comprehensive, bio-behavioral, individualized, treatment plan. Important components of treatment are:
* DETOXIFICATION: The first phase for those with physical withdrawal symptoms must be performed in a safe setting.
* EDUCATION for the addict about the disease of addiction.
* GROUP THERAPY: Understanding the disease through the group process.
* INDIVIDUAL THERAPY: Focusing on the addict’s interpersonal issues.
* FAMILY THERAPY: Co-dependency issues are identified and worked through.
* RELAPSE PREVENTION: Guidelines for the recovering addict to rely on when faced with life stressors that may precipitate relapse behaviors
* SUPPORT GROUPS: The most successful recoverees fully participate in support groups such as NA or AA, which include working the 12 steps and confiding in a sponsor. The heart of NA and AA’s program is total lifetime abstinence from alcohol and drugs-one day at a time. In Connecticut, there is also an anonymous, confidential peer support group for recovering nurses called Nurses for Nurses. This is a group of nurses in various stages of recovery and is a significant resource for nurses facing all issues of addiction.
Treatment non-compliance is the biggest cause of relapses for all chronic illnesses, including asthma, diabetes, hypertension, and addiction. For drug addiction, as well as for other chronic diseases, the individual’s motivation and behavior are clearly important elements of success in treatment and recovery.
Predisposing Factors for Nurses
Specific factors predispose the nurse to this disease and actually allow for the initiation and continuation of substance abuse.
EDUCATION-We witness the cause and effect of medications. Drugs DO work!
* Alleviating the suffering of patients
* No emphasis on consequences of misuse
* Presumption that education equates immunity
* Ignoring the fact that it is an occupational hazard
* A blind faith in drugs develops
* Pavlovian response-reach for a pill or shot to relieve pain and suffering
* Self-diagnosing leads to self medicating
ACCESSIBILITY OF NARCOTICS
* Easy access leads to higher probability of use and abuse
* Rotating shifts-leads to disrupted sleep patterns and sleep deprivation
* Expectation that nurses must “control” emotions
* Heightened acuity level of care, fewer nurses, reduced time frame to complete nursing care
* Lack of support when crisis situations arise and lack of praise when crisis is resolved
Two major forms of enabling are:
* Lack of knowledge of addiction
* Lack of knowledge of the dynamics of recovery
* Fear of being manipulated
* Feeling powerless confronting a co-worker
* “No talk” rule-fear of litigation
* Rationalizing employee’s behaviors
* Allowing sloppy performance
* Lightening the employee’s workload
* Offering excuses
* Termination of employee
These forms of enabling are dangerous. The cycle continues to put the patients in jeopardy as the nurse becomes increasingly ill. Enabling robs the addicted nurse of the experiences that could propel them toward treatment and recovery.
The attitude held toward addiction interferes with the very spirit of nursing. It is hard to change the widespread attitude around addiction. We are not responsible for the attitudes we were raised with, but we can change them through education. We can then conduct our practice from an informed stance, offering the best we have to our patientsor our fellow nurses. Do we blame the cardiac patient or the diabetic for their illness? No, but we ask them to follow specific guidelines and take responsibility for the management of their disease and recovery. It is unethical to have a prejudicial attitude toward any disease or patient.
The need for change
The present system fails because there is no mandate for treatment and no standards for impaired nurses in Connecticut.
* Is a disciplinary model
* Process is slow-can take up to a year from the time of discovery until probation takes effect.
* Lacks confidentiality-everything is a matter of public record
* Fear of disclosure and licensure issues prevent the nurse from seeking treatment
* Is not recovery oriented
* “Captures” nurses only identified by diversion– offers little/no help for the nurse addicted to street drugs/alcohol
* Places NO constraints on the license initially
* There is no assessment of the nurse’s fitness to return to work, readiness to end probation and no positive guidance or direction for the recovering nurse.
* Inconsistent and unenlightened monitoring once probation is in effect
Thirty-seven other states have alternative to discipline programs that are extremely effective in helping the impaired nurse maintain their health, their life and their profession.
Alternative to Discipline Program
* A contracted agreement
* Confidential and non-threatening
* Ensures public safety by encouraging recovery
* Early identification is key
* Immediate entry into treatment
* Agreement not to work until cleared by program
* Safe return to practice
* Highly structured monitoring by a diverse team of addiction professionals using a case management model
* Mandatory attendance at structured recovery nurse support groups
* Identification of relapse behaviors in the early stages, with appropriate counseling and guidance
* Completion of mandatory relapse prevention modules before consideration for release from contract
What should you do if you suspect that a nurse is impaired?
* Document any behavioral changes along with corroborated evidence to support your suspicions.
* Notify your Nurse Manager or Director of Nursing.
* If appropriate, refer the nurse to “Nurses for Nurses”
It is essential to remember that denial is the hallmark of addiction and is the basis for the rationalizations that keep the addict-nurse continuing with addictive thinking and behaviors. EDUCATION is what is needed to stop the enabling and help the thousands of our peers whom are at risk for this lethal disease. This is an opportunity for all of us to participate in the metamorphosis of our contemporaries and uphold the Code of Ethics for Nurses. Take a stand to unify our profession and provide for our own. Be a part of the spirit that is nursing.
Addicts are not “bad” people trying to get good ..They are sick people trying to get well.
by Dede Dwyer, RNC
Patricia Holloran, RN
Karen Walsh, BSN
Copyright Connecticut Nurses’ Association Mar-May 2002
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