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Substance Use Disorder (SUD) �in Nursing: �Awareness and Prevention: �Part 1

These educational materials were developed through a collaboration with the Minnesota State Board of Nursing, the University of Minnesota School of Nursing, the Nurse Peer Support Network, and MHealth. Dina Stewart, DNP, APRN, PMHNP-BC created the learning materials and has given permission for the University of Minnesota School of Nursing to disseminate the materials to schools of nursing in Minnesota.

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Objectives

Describe the risk factors and protective factors of substance use disorder for nurses

Clarify personal values related to substance use disorder in order to address the stigmatization of nurses with substance use disorder

Outline the professional, personal and legal consequences for nurses with substance use disorder

Describe the signs of an impaired nurse in the workplace

Identify evidence of diversion in order to have awareness in a clinical setting

Identify approaches to engaging peers and managers regarding substance use disorder related concerns

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Substance Use Disorder: Review

Substance Use Disorder is a pathological pattern of behavioral, cognitive and physiological symptoms related to the use of a substance, that an individual continues to use despite significant interpersonal, occupational or physical problems (DSM 5, 2013).

It is a chronic disease, not a moral deficit.

People recover.

In practice and in the literature, you may see and hear terms like – addiction, chemical dependence, alcoholism, substance abuse. To keep things simple, the term Substance Use Disorder will be used in the module. It covers the spectrum of chemicals that are used and abused as well as the varying levels of severity of use.

Here is the definition per the DSM 5 for substance use disorder. “a pathological pattern of behavioral, cognitive and physiological symptoms related to the use of a substance, that an individual continues to use despite significant interpersonal, occupational or physical problems” The important detail to take away is that an individual continues to use the substance despite significant problems.

You have had previous education in the nursing program that discussed Substance use disorder among your patients. The concepts you learned apply when thinking about Substance use disorder and your fellow nurses. It is a chronic disease. And there are evidence-based treatments for it. People recover.

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Definitions

Impairment – inability to perform work related activities safely

Diversion – transfer of a controlled substance from the person it was originally prescribed to another individual for an illicit use.

Some more terms that will be discussed frequently in this presentation are the concepts of impairment and diversion.

�Impairment is the inability to work safely. Impairment can occur due to physical or mental illness. In this case, we are talking about impairment probably due to either being under the influence of alcohol or other drugs, or it could be due to a withdrawal syndrome related to recently using a drug. Either way, the person is impacted in such a way that they are not thinking rationally, possibly not alert to the needs of the patients, or maybe taking a lot of breaks, so that patient care is compromised.

Diversion is taking medication that has been legally prescribed to a patient and instead of administering the medication, the nurse pockets it and uses herself, or takes it somewhere else. Diversion is any act that takes a medication from a patient. So it is essentially stealing. And it is a felony if it caught and prosecuted.

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Why should I care about SUD in nursing?

Why are you learning this?

There are many work related issues you will experience as an RN that go beyond nursing diagnoses and care plans AND NURSES WITH SUBSTANCE USE DISORDER IS ONE OF THOSE WORK RELATED ISSUES. Substance use disorder is a serious AND PERSISTENT nurse practice issue. THE INFORMATION WE WANT YOU TO LEARN IN THIS MODULE IS INTENDED TO INCREASE YOUR AWARENESS OF THE ISSUE. YOU WILL ENCOUNTER SUD IN PRACTICE—IT COULD BE YOU OR A CO-WORKER.

Nurses need to know the risk factors for SUD in order to engage in prevention for YOURSELF AND YOUR PEERS AND OTHER HEALTH CARE PROFESSIONALS

You need to be able to recognize peers who might be impaired and at risk for harming patients.

The American Nurses Association, National Council on State Boards of Nursing, the American Association of Nurse Anesthetists and many other nursing organizations have identified substance use disorder among nurses an important topic for nurses entering the profession.

Nurses experience SUD at the same rate as the general public ~ 10% (Monroe, Kenaga, Dietrich, Carter & Cowan, 2013). THAT MEANS THAT THERE ARE OVER 300,000 NURSES WITH SUD.

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Society’s Image of Nursing

Nurses:

Held to high standards by society
Are trusted by the public (yearly Gallup poll rankings)
Experience professional and/or personal failure to meet these high expectations when SUD is diagnosed (Shame and stigma)

“Nurses #1 in Honesty, Ethics since 2001 --Gallup Poll, December 2016

Nurses:

Held to high standards by society

Are trusted by the public (yearly Gallup poll rankings)

Experience professional and/or personal failure to meet these high expectations when SUD is diagnosed (Shame and stigma)

Nurses’ image among the public contributes to the challenges nurses have asking for and accepting help. We see our profession as having high standards. To engage in a dialog that acknowledges some nurses have substance use issues is taboo among nurses. We want to think that it is the exception for a nurse to have a Substance use disorder. Is a 10% prevalence rate an exception? It seems pretty high when you think 1 in 10 nurses are affected by it. Recognizing that simply working in the nursing profession increases the risk for nurses of developing substance use disorder and framing substance use disorder as a chronic disease instead of a personal failure is a positive step for the nursing profession to make.

Part of the disease process of Substance Use Disorder, is denial that there is anything problematic with the substance use or associated behavior.

This further jeopardizes a nurse, who has a problem, but has little insight as to the impact of the use, heightening the need for nurses to intervene when a peer is suspected of being impaired.

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Risk factors for development of substance use disorder:

Attitudes
Access
Stress
Lack of education about SUD

Review this resource: National Council of States Boards of Nursing (NCSBN). (2011). Substance use disorder in nursing: A resource and guidelines for alternative and disciplinary monitoring programs. Chicago: NCSBN.

Entire document is available here: https://www.ncsbn.org/SUDN_11.pdf

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Risk Factor--ATTITUDES

Medications solve problems
I need to work
I am invulnerable to illness
It is acceptable to use substances to cope with stress

General Attitudes of nurses are a big risk factor for developing Substance Use Disorder. This picture of an iceberg is meant to be a representation of what guides decisions and actions. The tip of the iceberg above the surface are your knowledge and skills, but the huge portion under the surface, are your attitudes – your beliefs, values and emotional responses. Attitudes shape how we view the world and how we conduct ourselves professionally.

There are many underlying attitudes of nurses that put them and greater risk for developing problematic substance use. The first is that Nurses are trained to see medications as the solution to physical problems. Nurses have vast knowledge of medications and physical disease processes which leads to self-diagnosis. Many of the nurses who experience substance use disorder report that the problematic use started when trying to cope with an injury.

Another attitude is the idea that nurses need to work through their pain. There is a nursing shortage. Many units are short staffed. A nurse could rationalize self-medication thinking, “If I call in with back pain, then we’ll be short staffed”. “I can’t take time off to let my back heal – I need to work. My patient’s need me”. Nurses tend to put the needs of others before engaging in self care.

Additional attitudes are that nurses often feel invulnerable to illness. We see ourselves as the caregiver and not capable of being vulnerable to developing and problems.

And probably the most problematic attitude among nurses is that substances are seen as an acceptable way of coping. It is socially sanctioned to engage in alcohol as a way to transition from the stress of work. How many of you have thought of having a drink after clinical even before the shift was half over? The more difficult the day, the more you say to yourself – “I will need a drink after this shift!” It is the acceptance of substances as coping that is problematic for the individual who starts to have consequences as a result of the use.

(NCSBN, 2011)

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https://www.pinterest.com/pin/290763719669161290/

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Risk Factor: Access

Nurses are the primary health professionals that administer medications to patients.
Access leads to diversion
Having the knowledge and ability to easily obtain substances is a factor that increases the risk for nurses

The next risk for development of substance use disorder for nurses is access – this includes access to drugs and medication themselves, as well as access to knowledge related to disease processes – to know what to report in order to get prescribed controlled medication and even how to write a prescription.

Nurses are the primary profession that administer medications to patients. Many health care facilities have processes and policies in place to minimize medication errors, however, there is still the human element of needing to unpackage the medication prior to administration. Diversion occurs when medication intended for a patient is used in another way – could be used by the nurse who diverted, could be sold or used in another way. You have a huge moral, legal and ethical responsibility when administering medications.

Nurses have been known to forge prescriptions, or call in orders to a pharmacy supposedly from a prescriber.

Nurses have knowledge of disease processes and know what to emphasize with prescribers in order to get a prescription for opioids for pain if needed.

Some nursing worksites provide nurses easier access to medications because they need to be given quickly: critical care areas and the emergency dept, for instance, which incidentally, have higher rates of nurses with SUD.

Having the knowledge and ability to easily obtain substances is factor that increases risk for nurses.

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Risk Factor: Stress

There are many factors in the workplace that contribute to nurses experiencing stress.

Life and death situations
Trauma, emergencies
Staffing shortages
Patient turnover
Rotating shifts
Workplace incivility

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Risk Factor: Lack of education

Diminishes awareness of SUD as an issue and perpetuates SUD as a stigma
Nurses contribute to stigma by making judgmental statements about patients with substance use disorder

There are currently gaps in education regarding substance use disorder among nurses in nursing education as well as in practice settings. If nurses are not aware of the risks and consequences of SUD, they cannot be fully engaged in prevention.

You are learning about SUD and nurses in response to this risk factor.

The lack of education diminishes awareness of substance use disorder as an issue and also contributes to the perpetuation of stigma. Stigma is defined as socially imposed public disapproval of people who experience substance use disorder. Nurses contribute to stigma by making judgmental statements about patients with substance use disorder

“This patient was such a junkie, and now she has HIV. That’s what you get when you are an IV drug user?” Or “this guy shouldn’t get a liver transplant, so what if he’s been sober for 5 years, he wrecked his liver by being a lush.”

Do these statements sound shocking to you? Nurses who have problems with, or are currently in recovery from SUD, will not feel safe in this environment asking for help among their manager or peers at work.

Take the challenge of looking deeper and see individuals as more than their current problem. The “junkie” patient may have untreated PTSD. The liver transplant guy has 5 years of sobriety which is a significantly big deal.

STIGMA and SHAME are found in all the literature about SUDs in nurses as a barrier to nurses receiving treatment for their substance use disorder.

LACK OF EDUCATION PERPETUATES STIGMA within the culture of nursing! Avoidance of facing possible SUDs often occurs due to fear of repercussion and discrimination at work and leads to nurses not getting timely help for their SUD as they have directly or indirectly witnessed a culture of mistreatment of those with SUDs in nursing.

Treatment and recovery are more challenging the further into the disease the nurse is. As a profession, nursing needs to work to turn this around and start getting nurses into treatment and recovery earlier in the disease process

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Protective Factors

Supportive work environment
Adaptive self-care
High work satisfaction
Older age

(NCSBN, 2011)

There has been much more study of risk factors regarding SUD among nurses than protective factors. What has been identified in the literature are supportive work environments, good self-care, feeling satisfied with work and being older – this means that as nurses age, they are less likely to develop Substance use disorder.

What about addressing each of the big risk factors as a way to foster prevention:

Assessing your attitude and values towards substance use disorder, and acknowledging whatever biases are there, will help you remain objective when caring for patients with substance use disorder or if concerned about a peer.

Ensuring that your workplace has appropriate policies and procedures around medication administration and suspected staff impairment.

Engaging in positive coping strategies for managing the stress of working in the situations nurses experience.

Educating yourself regarding the issue and talking about it openly with peers – this will normalize conversations that feel taboo.

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Practice Issues / Consequences

Health of affected nurse – Physical, emotional, spiritual

Legal issues if the nurse is diverting drugs; drug diversion is a felony

Patient Safety – Impaired nurse leads to impaired judgement. Diversion leads to patient not receiving needed medication

Impact on healthcare systems – Absenteeism, liability

Impact on nursing profession – Careers are jeopardized

Personal consequences for a nurse with untreated SUD is that it impacts physical, emotional and spiritual health. You know from learning about holisitic nursing care, that when one area is impacted, it affects the all other areas. Substance use disorder can be life threatening, especially with opioid use. Overdose is always a risk. Another personal consequence is that Nurses with SUD have jeopardized their means to livelihood – the nursing license. Nurses work hard to earn the license; it’s precious and valued by most nurses.

Legal Consequences are related to drug diversion. Drug diversion is a felony and if prosecuted the nurse will have a criminal record. Additionally, when applying for a nursing license in Minnesota, there is a question about having been treated for chemical dependence. “In the last five years, have you ever misused or abused alcohol, other drugs or chemicals or been considered chemically dependent?” This question is asked when you apply to renew your license.

Professional consequences include jeopardizing patient safety due to the nurse’s potential impaired cognitive state and impaired judgment, or issues of diversion

Nurses with SUD often excel at what they do – they are often excellent nurses and it’s a loss to the profession when jobs and licenses are lost due to SUDs. Their careers are worth saving. With looming nursing shortages, they need help to succeed in recovery.

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References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Gallup (2015). Americans’ faith in honesty, ethics of police rebounds. Retrieved from: http://www.gallup.com/poll/187874/americans-faith-honesty-ethics-police-rebounds.aspx

Monroe, T. B., Kenaga, H., Dietrich, M. S., Carter, M. A., & Cowar, R. L. (2013). The prevalence of employed nurses identified or enrolled in substance abuse monitoring programs. Nursing Research, 62(1), 10-15.

Monroe, T., & Kenaga, H. (2010). Don't ask don't tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 504-509.

NCSBN. (2011). Substance use disorder in nursing: A resource and guidelines for alternative and disciplinary monitoring programs. Chicago: NCSBN.