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Substance Abuse in Nursing: What Are the Signs and What To Do About It?

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By Frieda Paton, M.Cur, RN

Do you suspect that a co-worker is abusing drugs or alcohol and impaired while at work? What are the signs? What should you do about it?

The American Nurses Association suggests that up to 10% of nurses may have a substance abuse problem, and some studies have suggested that this might be as high as 1 in 5. Many of these nurses are addicted to prescription drugs and part of what the CDC describes as the opioid addiction epidemic. Numerous addicted nurses have not been long-term abusers but get caught in the trap of tolerance and dependence after having the drugs prescribed or having self-medicated after emotional trauma.

The nurse who is impaired by drugs or alcohol mostly believes that she is fine but is, in fact, unable to care for her patients safely and effectively while her behaviors may actually be putting their lives in danger. If you suspect that a co-worker is a substance abuser, it is your ethical duty towards patients, the community, your profession and your employer to make our concerns known.

The Signs of Substance Abuse

The path to addiction is a gradual one. It starts with abuse, or illegal use of a substance, which can lead to tolerance requiring ever higher doses of the drug to get the same effect. For some, this then leads to addiction where they crave the drug and are no longer able to stop using it – at this stage the drug use is a brain disorder causing compulsive behavior which the addict cannot control.

Addicted nurses are not easy to recognize. The typical signs and symptoms of substance abuse and addiction which we learn about may not be evident in a nurse who is employed when compared to the down-and-out addict in the street. They tend to take extra care to avoid detection and, because of free access to the drugs, clean needles and syringes, the habit does not have the same financial drain it does for other addicts. 

Physical signs 

Nurses are as likely as other addicts to show the same physiological effects of the abused substance, which may include:

  • Shakiness and tremors
  • Dilated or constricted pupils (opiates cause constriction)
  • Watery eyes and nose
  • Fatigue with slowed breathing, nodding off to sleep or even blackouts
  • Slurred speech
  • Moving unsteadily
  • Frequent episodes of nausea, vomiting and/or diarrhea
  • Unusual weight loss or gain

An untidy appearance, with poor grooming, is generally listed as a physical sign of addiction but addicts who are employed may take extra care with their grooming to keep up a normal appearance.

Changes in behavior 

If a nurse has not had a long standing problem with substance abuse, changes in behavior might be the first thing co-workers notice. On the other hand, they may take place gradually over time and only become evident when looking back on the person’s past behavior. Behavioral signs may include:

  • A lack of concentration, with forgetting and frequent errors
  • Hyperactivity and euphoria, joking and laughing a lot and seemingly not affected by the stress of the job
  • Hypoactive, not carrying their full load of the work to be done
  • Decreased quality of care and in documentation
  • Isolation from their co-workers and problems with personal relationships
  • Frequent anger and defensive behavior
  • Arriving for work late, frequent requests to leave early and calling in sick often
  • Always on the job, willing to work late or extra shifts (because that’s where the drugs are)
  • Lying, to the extent that they are caught out
  • Brief and unexplained absences from the unit or frequent trips to the bathroom
  • Wearing warm clothing even in hot weather, to hide needlestick marks

Signs of substance diversion on the unit 

There are many clever ways in which addicted nurses feed their ever-increasing craving for drugs, which takes priority over patient care as well as their own better judgment. The frequent occurrence of one or more of the following should serve as a red flag:

  • Increased narcotics sign-outs when a specific nurse is on duty.
  • Frequent errors in narcotic counts, narcotic records or patient’s medication records.
  • An unusual number of requests for signing out wasted narcotics. (How often doesn’t it happen that co-workers co-sign but don’t actually check that their trusted colleague, in fact, disposes of the drug?)
  • A particular nurse’s patients regularly complaining of not having the expected pain relief even after receiving their pain meds.
  • A nurse who regularly offers to give co-workers’ patients their medication.
  • Changes made to verbal or telephonic orders for narcotic medication.

What you should do if you suspect a co-worker?

Firstly, you should not resort to enabling behavior – something nurses tend to do because they are carers and protectors. Enabling behavior includes ignoring or covering up poor performance and errors, reducing the nurse’s workload, accepting excuses and giving in to manipulation. Whether it’s because you don’t want to become involved, wish to avoid confrontation, unsure of what you can do, or would like to protect your colleague, don’t look the other way. An impaired nurse is a real threat to her patients.

If you suspect that a co-worker is abusing substances or already addicted, go back to the literature and sharpen your knowledge on the associated signs, symptoms and behaviors. Also, collect information on the workplace policy and procedures relating to substance abuse by employees, and what assistance might be available either in the workplace or from your local nursing association. Find out what policy your Board of Nursing follows with regard to impaired nurses. Increasingly, the trend is to support rehabilitation and reintegration into the workplace after treatment, rather than to enforce harsh disciplinary action.

The next step is to document all the facts that support your suspicions about the nurse and, armed with this information, discuss the matter with a nursing services manager. If you are close to your co-worker, and especially if the person has confided in you about his or her problem, try to encourage the nurse to find help before being caught out. You can also advise and support your colleague in this process.

It may be a very difficult decision for you to take action but we have an ethical duty to protect our patients. Nurses also need to show the same care and compassion for co-workers who have a problem as for their patients. Few addicts will reach out for treatment voluntarily and will only do so once confronted by others or when facing the possibility of losing their jobs. However, those nurses who enter a structured treatment program have a good chance of recovery and returning to their profession.

Frieda Paton is a registered nurse with a Master’s degree in nursing education. Her passion for nursing education, nursing issues and advocacy for the profession were ignited while she worked as an education officer, and later editor, at a national nurses’ association. This passion, together with interest in health and wellness education since her student days, stayed with her throughout her further career as a nurse educator and occupational health nurse. Having reached retirement age, she continues to contribute to the profession as a full-time freelance writer. In the news and feature articles she writes for Nurseslabs, she hopes to inspire nursing students and nurses on the job to reflect on the trends and issues that affect their profession and communities - and play their part in advocacy wherever they find themselves.

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