IDENTIFYING IMPAIRMENT
Substance abuse in the workplace can result in serious consequences when it is not recognized and treated early. In healthcare settings it is often unidentified, unreported, and untreated for long periods of time.
The Nurse Worklife and Wellness Study found that in the year prior to the study illicit drug use among nurses was 5.7% and misuse of prescription drugs was 9.9% (Trinkoff et al., 2022). The exact number of nurses afflicted is unknown, but the prevalence of addiction among nurses is believed to mirror the general population. In 2020, an estimated 37.3 million Americans aged 12 or older were current illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 13.5% of the general population ages 12 or older (SAMHSA, 2021).
Nurses may be at increased risk for abuse of prescription-type medication due to the added risk of working in environments where frequent and easy access to controlled substances is part of their daily work routine. Evidence suggests the types of drugs abused by nurses may depend on what drugs are most accessible in their individual work environments. The most common prescription drugs abused by nurses are benzodiazepines and opioid analgesics. Nurses who abuse prescription drugs are those who have the greatest access, such as nurse anesthetists (AAC, 2022). Access to drugs is one of the most cited risk factors for nurses who present with impaired practice. In emergency departments, ICUs, and other settings where nurses have more autonomy, the risk appears to be worse (Cares et al., 2015).
The U.S. Drug Enforcement Agency (DEA, 2020) regulates five classes of drugs that are most frequently abused. These include opioids, depressants, hallucinogens, stimulants, and anabolic steroids. Fentanyl is the most commonly diverted drug, and it is also the drug most responsible for opioid overdose deaths. This is of particular concern, since substance use disorders in the United States have reached epidemic proportions, and overdoses involving opioids rose approximately 75,770 in the year ending April 2021, 56,000 more than the year before (CDC, 2021).
Determining the prevalence and patterns of substance use disorder in the nursing profession has been challenging because denial and fear of legal and professional repercussions promotes silence among nurses. Those who struggle with addiction tend to minimize the problem, acknowledging it only when faced with serious consequences.
Colleagues may notice unusual changes in behavior but may not be equipped to recognize signs and behaviors associated with substance use, impairment, or diversion and often misread cues or look for other explanations. Sadly, by the time colleagues and supervisors take action, the impaired nurse has often progressed to the later stages of addiction, where patient safety is most at risk.
In recent years, significant progress has been made toward developing programs aimed at early identification and treatment of nurses with substance use disorder and other mental health conditions that may impair practice. Often referred to as “alternative to discipline,” these programs enable the nurse with SUD to avoid disciplinary action and return to work under strict monitoring that ensures public safety and holds the nurse accountable to treatment and ongoing recovery.
More than 40 states (including Florida), the District of Columbia, and U.S. territories have developed programs aimed at helping nurses get treatment as an alternative to discipline (Smiley & Reneau, 2020). (See also “Intervention Project for Nurses” later in this course and “Resources” at the end of this course.)
It is imperative that all nurses learn the signs and symptoms of impairment and learn to recognize drug diversion. Additionally, nurses must be empowered to stop, question, and act. They must have organizational support to speak up when something seems abnormal or unsafe.
Risk Factors for Substance Abuse
While the prevalence of substance abuse among nurses is believed to mirror the general population, the associated consequences of impairment may be far more devastating. Nurses provide direct care to more patients than any other healthcare professionals. This puts nurses in a position of great accountability. All nurses must be aware of risk factors for substance abuse and be able to recognize and respond appropriately to impairment in the workplace.
Nurses face the same risk factors for substance abuse as anyone in the general population. Similar to the general population, they have genetic predispositions, social pressures, and coping difficulties that make them vulnerable. Some nurses have a long history of using alcohol or other drugs, and some with no previous history of substance use turn to drugs or alcohol as a means to cope when stressful life events occur, such as divorce, loss of a loved one, an accident, or illness.
In recent years, trauma has become a well-recognized risk factor for SUD. Nurses experience traumatic events in the course of their daily work life. Second victim trauma may be related to human errors made by nurses or adverse events that occur in the workplace. This second victim trauma can lead nurses to experience anxiety, guilt, depression, or shame, which can all contribute to an increased risk for substance abuse (Foli et al., 2021).
The Nurse Worklife and Wellness Study found nurses in home health/hospice and nursing homes/long-term care reporting higher rates of illicit drug use and prescription drug misuse (Trinkoff et al., 2022). However, because of confidentiality issues related to studying affected nurses as well as stigma and the fear nurses have of reporting, it is difficult to know the full scope of the problem.
WORKPLACE RISK FACTORS
Nurses may be particularly vulnerable to abuse of controlled substances simply because of the nature of the profession and the workplace environment. Nurses have specialized knowledge about the effects of controlled substances, and with every administration, they witness the calming and euphoric effects of controlled substances on their patients.
Other workplace risk factors include:
- High-stress work environment
- Low job satisfaction
- Role strain
- Long hours and irregular shifts
- Fatigue
- Periods of inactivity or boredom
- Remote or irregular supervision
- Easy access to controlled substances
- Lack of education regarding substance use disorders
- Nursing attitudes toward drugs
- Lack of pharmaceutical controls in the workplace
- “Enabling” by peers and managers
(Addictions.com, 2021; Smith, 2021)
GENERAL RISK FACTORS
While workplace factors contribute to substance abuse, nonworkplace factors are likely to play a much larger role. According to the National Council on Alcoholism and Drug Dependence, the single most reliable indicator for risk of future alcohol or drug dependence is a family history. Scientists estimate that genes, including the effects environmental factors have on a person’s gene expression (called epigenetics), account for 40%–60% of a person’s risk of addiction (NIDA, 2020). Family history, personality characteristics, underlying comorbid conditions such as depression or anxiety, and inadequate coping skills may pose the greatest risk for SUD in nurses (Smith, 2021).
| Type | Risk Factors |
|---|---|
| (NIDA, 2020; Toney-Butler & Siela, 2020) | |
| Genetic |
|
| Physical |
|
| Psychological |
|
| Behavioral and social |
|
Signs of Impairment and Diversion in the Workplace
Impairment renders a nurse unsafe to provide patient care. Physical, psychosocial, and behavioral clues, however, can be subtle and easily overlooked. Colleagues may notice clues but seek other explanations and avoid suggesting substance abuse as a possible cause.
RECOGNIZING IMPAIRMENT
Generally, disruptions in family, personal health, and social life manifest long before a nurse shows evidence of impairment at work. Thus, all indicators, no matter how subtle, appearing in the workplace must be taken seriously. Any of the following may be signs of impairment in the workplace, and patterns of such behavior and a combination of these signs are cause for increased suspicion.
| Type | Signs |
|---|---|
| (Nyhus, 2021; AANA, n.d.; Toney-Butler & Siela, 2020) | |
| Physical |
|
| Psychosocial |
|
| Behavioral |
|
DETECTING DRUG DIVERSION
In the United States, diversion of opioid medication has contributed to an epidemic of opioid abuse and overdose deaths, and fentanyl, one of the most potent opioids, is the most commonly diverted drug. Nurses have frequent and easy access to controlled substances, providing ample opportunity for an addicted nurse to engage in diversion. Nurses in some specialties, such as anesthesia, intensive care, and emergency, have been identified as more susceptible because of increased exposure in these departments. Clearly, the opportunity for diversion of controlled substances from the workplace exists, and diversion of opioids is seen across all clinical disciplines and all levels of an organization, from management to frontline staff (TJC, 2019).
Diversion may occur with opened or unopened vials, partially used doses of medication that are not wasted, and medication that has been disposed of and left in sharps containers. The drugs most commonly diverted from healthcare settings are opioids, but there is no precise data that defines the extent of drug diversion.
Systemwide initiatives should be in place in all clinical settings to detect drug diversion, and all employees should be made aware of protocols in place. Every nurse plays an important role in drug diversion prevention and should be able to recognize patterns, trends, and behaviors associated with drug diversion.
Patterns and trends that may indicate drug diversion include the following:
- Compromised product containers
- Frequent medication losses, spills, or wasting
- Controlled substances removed without a doctor’s order
- Controlled substances removed on recently discharged or transferred patient
- Controlled substances removed for a patient not assigned to the nurse
- Medication documented as given but not administered to the patient
- Patients complaining of ineffective pain relief
- Frequent unexplained disappearances from the unit
- Incorrect narcotic counts
- Consistently documenting administration of more controlled substances than other nurses
- Large amounts of narcotic wastage
- Numerous corrections on medication records
- Offers to medicate a coworker’s patients for pain
- Frequent trips to the bathroom
- Saving extra controlled substances for administration at a later time
- Altered verbal or phone medication orders
- Variations in controlled substance discrepancies among shifts or days of the week
(AANA, n.d.; Nyhus, 2021; Tellson et al., 2022)
CASE
Agnes has been a registered nurse in the postanesthesia care unit for more than 10 years. She is a highly skilled nurse, always punctual, well prepared, and meticulous about the care she provides to patients. She has been a preceptor to many new nurses and serves on the unit quality care committee.
Less than a year ago Agnes was involved in a motorcycle accident that required her to be off work for six months. In addition to the road burns that covered her body, she had a fractured tibia, fractured ribs, and a neck injury. She started back to work about three months ago.
Her colleagues are concerned because they have noticed a change in Agnes’s personality and behavior. She is frequently late for work and always has elaborate excuses that don’t make sense. While she used to spend time in the lunchroom socializing during breaks and lunch, now her coworkers rarely see her. In fact, one coworker commented that they were not able to find her on more than one occasion.
The charge nurse on the evening shift noticed that Agnes was signing out a lot more narcotics and documenting more wasted medication than other nurses. One day a patient complained she did not get relief from pain even after Agnes gave her pain medication. The charge nurse discussed the patient complaint with Agnes, who became very defensive, insisting that she gave the patient the medication as ordered and accused the patient of “drug seeking.”
There were no physical signs that Agnes was impaired at work, and the charge nurse never noticed obvious manifestations such as an unsteady gait, slurred speech, or nodding off. But due to their concerns, she and the clinical manager decided to document the complaint, pay closer attention to behavior patterns, and document any additional concerns. They also planned to audit Agnes’s patient charting for any unusual medication dosages or discrepancies. They reviewed the hospital policy and the state requirements for reporting to be better prepared if further action became necessary.
On a particularly busy day at work, Agnes could not be located to admit a new patient coming from surgery. Another nurse had to admit the patient while the charge nurse went to look for Agnes. She found Agnes at a desk in the back hall with her head down on the desk. She was slow to arouse, raising serious suspicion for the charge nurse. The clinical manager was immediately notified and an intervention for impaired practice was planned.
Consequences of Impairment in the Workplace
Impairment from substance abuse, drug diversion, or other physical or psychological causes has far-reaching impact. It not only threatens the health and safety of patients but also creates serious consequences for the impaired professional, colleagues, and the healthcare facility that employs the impaired nurse.
| Impacted Party | Possible Consequences |
|---|---|
| (Rousseau, 2020; Toney-Butler & Siela, 2020; Nyhus, 2021) | |
| Patient |
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| Impaired professional |
|
| Colleagues |
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| Facility |
|