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[narrator] Sarah isn't sure how she got to this point.
As a nurse, Sarah works in a high stress environment
and recently went through a difficult divorce.
After a back injury, Sarah began taking pain medications
prescribed by her doctor.
When her prescription ran out, she began borrowing medications
from floor stock, then, using medications that should have been discarded.
Now, Sarah is diverting medications intended for her patients,
and attempting to conceal that diversion from co-workers and supervisors.
Sarah's story illustrates one of the most serious problems
facing the nursing profession today.
Substance Use disorder.
Nurses who abuse substances pose a unique challenge to the profession.
The behavior that results from this disease has far reaching
and negative effects.
Not only on nurses themselves, but also upon the patients
who depend on the nurse for safe, competent care.
Substance use disorder, among health care providers
also creates significant legal and ethical responsibilities
for colleagues who work with these individuals.
But, there's good news too.
When employees think their supervisors knows how to detect substance abuse
and is willing to do something about it, employees drinking and drug use decreases.
Your role as a colleague or supervisor of the nurse who has a substance use disorder
is pivotal. Be armed with knowledge.
First, identification and reporting of the problem, next, intervention.
Then, diagnosis and treatment of the substance use disorder
and finally, monitoring of the nurse, after return to practice.
♪ [transition music] ♪
Substance use disorder encompasses a pattern of behaviors that range
from misuse to dependency or addiction.
Whether it's alcohol, legal drugs or illegal drugs.
Addiction is a complex disease with serious physical, emotional, financial
and legal consequences.
It can affect anyone, regardless of age, occupation, economic circumstances,
ethnic background or gender.
Substance use disorder is a progressive and chronic disease,
but also one that can be successfully treated.
Although alcohol is the drug of choice for the general population,
nurses have increased access to controlled substances,
contributing to higher incidents of dependence on them.
Regardless of thechemical, mind altering substances result in long lasting changes
changes to the brain, which is why addiction is a chronic
and relapsing brain disease.
The earlier substance use disorder in a nurse is identified
and treatment is started, the sooner patients are protected.
And the better the chances are of the nurse returning to work.
♪ [transition music] ♪
Nurses and other health care professionals have about the same prevalence
of substance abuse and addiction as the general public.
But, there are unique workplace factors that actually increase
a nurse’s opportunity and risk for addiction.
Staffing shortages, increased patient acuity and assignment ratios,
demands from administrators and physicians shift rotations and long work hours.
All of these issues make nursing a highly stressful profession.
In addition, some nurses are subject to workplace bullying and verbal abuse,
contributing to stress and feelings of powerlessness.
When someone is also experiencing personal problems or lacks effective coping skills,
this job-related stress may contribute to substance use.
Nurses also have relatively easy access to controlled substances
and other drugs of abuse.
Often times, the lack of institutional controls for storing
and distributing narcotics facilitates the improper removal of drugs
from floor stock, waste or even from a patient's medication supply,
for the nurses personal use, also known as diversion.
Many nurses use their education and experience to treat their own symptoms.
Because of that knowledge, they may have a false sense of confidence
and a belief that they could control their use of drugs.
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It's not always easy to recognize unsafe practices in a nurse
with substance use disorder.
Sometimes it's tough to differentiate between the subtle signs of impairment
and stress-related behaviors.
Three things to watch for are behavior changes,
physical signs and diversion of drugs.
Behavioral changes can include shifts in job performance, like absences
from the unit for extended periods, frequent trips to the bathroom,
arriving late or leaving early and an excessive number of mistakes
including medication errors.
Behavioral changes can also include subtle changes in appearance
that escalate over time, wearing long sleeves in warm weather,
increasing isolation from colleagues, inappropriate verbal or emotional response
or, diminished alertness, confusion or memory lapses.
When nurses are using drugs and unable to obtain them
from a treating physician, they may turn to the workplace
for access or diversion, often causing narcotics discrepancies.
These might include incorrect counts, large amounts of wastage,
numerous corrections of records, frequent reports of ineffective pain relief
from patients, offers to medicate co-workers patients
for pain, altered verbal or phone medication orders
and variations in controlled substance discrepancies among shifts
or days of the week.
Nurse managers and colleagues often don't recognize the warning signs
of the Substance Use disorder in a nurse co-worker.
They may misread cues and look for other explanations for behaviors.
In fact, many nurses with Substance Use disorder
are unidentified, unreported, untreated and continue to practice.
This finding highlights the need for education about Substance Use disorder
for all staff members.
It's especially important for the nurse manager to be able to address
the signs and symptoms of Substance Use disorder
in a transparent, supportive way.
Nurse managers should work to encourage open dialogue and educate staff
that Substance Use disorder is a medical condition, not a personal failure.
Nurse managers are also responsible for ensuring that co-workers understand
they have an professional and ethical responsibility
to report a colleague’s suspected drug use to the nurse manager
and in some states or jurisdictions, to their board of nursing.
♪ [transition music] ♪
When there's evidence of unsafe practice
or risk of harm to patients, the nurse manager must initiate
an internal investigation, develop a plan for intervention
rules about filing a complaint with the board of nursing.
An internal investigation might include documenting observations,
obtaining witness statements and the nurse’s admission in writing,
documenting diversion of drugs and referring the nurse for a drug screening.
A formal meeting often called an intervention, is appropriate
when there is sufficient documentation to show the nurse’s behavior is outside
of expected norms.
The goals of an intervention are to convince the nurse
that there is a problem and the problem is affecting patients
and colleagues and that help is available.
The nurse manager on Sarah's unit noticed her behavior changes,
changes in appearance and discrepancies in the medication audit.
After the nurse manager followed the facility policy and procedures
for an internal investigation, plans were made for a formal intervention.
Always lead by trained professionals, successful interventions are formal,
structured meetings of administrators and colleagues and may also include
other stake holders.
♪ [transition music] ♪
A nurse who has harmed patients, or, like Sarah,
has created a risk of harm because of substance use,
may need to be separated from practice and mandated to seek treatment
and fulfill other requirements.
Many boards of nursing offer non-punitive alternative-to-discipline programs,
ADP's which are voluntary non-disciplinary opportunities for nurses
with Substance Use disorder.
ADP approaches, which have been in place for more than two decades,
give nurses an opportunity for rehabilitation.
Unlike the more traditional disciplinary actions,
ADP's have the benefit of avoiding a long period
of investigation, in which the nurse can still practice and still place patients
at risk.
Because ADP requirements are determined in a private agreement,
they can help break through the denial of a nurse who fears the public notoriety
of discipline.
Nurses in these programs stay fully accountable to themselves,
a program monitor, a counselor, other nurses and supervisors.
Sarah's fortunate, because when she returned to practice,
her supervisor was well-oriented to her responsibilities in the ADP.
Her supervisor even completed specialized training that increased her knowledge,
sharpened her observation skills
and increased her willingness to assist Sarah in her return to work.
♪ [transition music] ♪
Treatment for Substance Use disorder does work and nurses in recovery
can re-enter the workplace safely when treatment and monitoring
are instituted.
Research demonstrates that Substance Use disorder
is treatable and that successful, long term recovery is possible
for those who maintain a rigorous relapse prevention program.
Because addiction causes changes in the brain, relapse is always a possibility.
Continuing care activities provide the nurse with professional support
for relapse prevention.
These activities typically include periodic random drug testing
and documented attendance at 12-step programs,
professional support groups and even individual counseling.
Similar to participation in an alternative to discipline program,
the nurse returning to work is subject to very structured
and specific guidelines.
A returned to work contract will identify a workplace monitor,
standards for work performance and conditions of employment
and require drug screening.
It may also set restrictions on practice, like restricted access
to controlled substances or not working the night shift.
♪ [transition music] ♪
Substance Use disorder is a challenging
and complex issue for the nursing profession.
But with supportive and educated supervisors and colleagues,
nurses with this disease can be identified more quickly
and receive the help they need.
The combination of identification,
successful treatment and careful monitoring,
ensures that the public is protected and allows recovering nurses like Sarah,
to safely return to practice.
♪ [transition music] ♪