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The American Nursing Association estimated (in 2007) that 10% to 20% of nurses have substance abuse problems. That is on par with or a little bit more than the number of people with substance abuse issues among the general public.
Stigma
Among the general public, there is a stigma about addiction. People hold addicts accountable and view addiction as a lack of effort or willpower on the addict’s part. That stigma is wrong, but it is popular. Even among medical health professionals who know that addiction is a brain disease, the negative stereotypes persist.
Stigma is one reason that many nurses dealing with substance abuse don’t speak up. In addition to loss of job, reputation, friends, and family, a nurse with a drug addiction also faces a breach of professional ethics, the endangerment of patients, and the loss of reputation for the facility that employs them.
Because of these risks, many nurses don’t speak up and many health care facilities lack sufficient support for nurses who do. But, how can you tell if a fellow nurse is abusing drugs?
Signs of Abuse
There is no single pattern of behavior that exists for all nurses grappling with addiction. But, there are commonalities and patterns that you can remain aware of.
A nurse who is abusing drugs will likely begin to make mistakes and be less productive at work.
“A Novel Approach to Monitoring Diversion of Controlled Substances: The Role of the Pharmacy Compliance Officer,” published in the March 2007 issue of Hospital Pharmacy, identifies three main categories of drug diversion:
- Straight theft
- Underdosing or substitution
- Theft charting
Straight theft involves removal of controlled substances for supply containers. Another method is the removal of partially used fentanyl patches from sharps receptacles for later personal use.
Underdosing may also involve nurses giving a portion of an injection to a patient and using the remainder. In some instances, staff will place a used fentanyl patch on a patient and save the fresh one for their use.
Substitution generally occurs when a nurse replaces the prescribed drug with saline, which allows the diverter to use the prescribed drug. This is popular in medical situations where the patient can’t fully express their pain level, allowing nursing staff to do it for them.
Theft charting encompasses chart forgery: signing out and documenting narcotic administration falsely, recording medication wastage falsely, diverting as-needed controlled substances by falsely charting their use.
Identification Markers
“A Novel Approach” also lists key markers that can be used to identify drug addiction in health professionals and they can be applied to your fellow nurses.
Deteriorating Job Performance
- Assumes less responsibility and withdraws from committees and activities
- Forgetfulness related to routine duties
- Sleepiness at work
- Cuts corners, dismisses details
- Decline in quality and quantity of documentation
- Ineffective use of work time
- Increased number of errors
- Increased absenteeism and tardiness
- Frequent profile overrides in the automated dispensing system
Psychological Indicators
- Mood swings with irritability
- Attitude change with increased anxiety and paranoia
- Social isolation
- Inability to get along with colleagues
- Challenges department policies and procedures
- Rationalizes negative feedback
- Defensive when questioned about errors or substandard patient care
Pre-Employment Factors
- Frequent job changes and/or relocations
- Frequent hospitalizations or accidents
- Reluctance to undergo a physical exam
- Unexplained gaps on resume
- Working at a job lower than education level
- Extensive travel or registry work experience
Changing Physical Appearance
- Decline in grooming and care of clothing
- Weight gain or loss
- Slight hand tremors
- Pupillary size change and/or bloodshot eyes
- Disorientation, unsteady gait, or slurred speech
Other Behaviors
- Preoccupied with medications and narcotics
- Voices global concern about inadequate management of patient pain
- Frequently checks narcotics supply and orders items from Pharmacy
- Increased use of as needed (PRN) narcotics
- Repeatedly uses inappropriately large syringes for small doses of controlled substance
- Charting trends demonstrate more withdrawal of narcotics than coworkers
- Waits for other colleagues to leave before accessing narcotics inventory
- Disappears at work; takes a break or visits restroom after removing narcotics
- Volunteers for extra shifts (particularly evenings and nights)
- Rarely takes vacation
Red Flags
- Pattern of heightened dispensing of more pain medications during a regular shift than coworkers
- Trend noted in patient complaints of ineffective pain control
If you are noticing these behaviors, it is your job to report your colleague. But, that isn’t an easy process or decision.