The Impaired Nurse

When Susan Scott, a nurse, noticed her husband, also a nurse, was hanging out at work on his days off, she thought he was having an affair.*

He wasn’t; he was diverting medications.

“I had no idea he had a drug problem until the day he was fired,” Scott said.

She knows now that her ex-husband was taking so much medication at work he could have easily overdosed. A nurse, acting on suspicion, reported him to his boss.

“Once he knew he was caught, he agreed to get help that day. He’s been in recovery for nearly a decade now,” said Scott.

Substance abuse has many common signs and symptoms that can vary among individuals. Change-in a person’s physical appearance, attitude, personality or behavior-is the biggest indicator and can be the key in recognizing substance abuse.

“Alcoholism and addiction do not discriminate, so a substance abusing nurse can look like any nurse,” explained Jeanna Smith, RN, director of nursing at Willingway, Statesboro, Ga.

To avoid detection, a substance abusing nurse will often use extra precaution and take measures, such as isolating from peers or frequent use of gum, mints or mouthwash to mask the odor of alcohol.

Jessica Cox, BSN, RN, said that while there are classic symptoms of substance abuse, such as disheveled appearance, isolation and changes in overall attitude, a nurse may hide the abuse very well.

The director of medication compliance at PharmaPoint noted that it may be difficult for colleagues to suspect substance abuse based on appearance alone.

“This is why focusing on change is so important,” said Smith. “While you might not notice alcohol on someone’s breath that is masked by gum, you will notice unexplained absences from the nursing unit, lack of pain relief from their assigned patients, frequent mood changes, unusual sleepiness or hyperactivity, or a change in personal grooming.”

Cox concurred that changes in behavior, attitude or appearance point to substance abuse, adding that isolation and physical symptoms are common as well.

According to the American Nurses Association, an impaired nurse is unable to meet the requirements of the code of ethics and standards of practice of the profession.

“Impaired nurses may neglect patient care, commit costly medication errors and even divert pain medication from a patient to themselves,” said Cox.

Even though some impaired nurses may appear to function well, the potential for harm exists, noted Smith, as an impaired nurse can impact their own health (hypertension, cardiovascular and liver disease, traumatic injuries, and even death by overdose, injury or suicide), personal life (lower self-esteem, anxiety/depression, financial hardships, legal issues, and the loss of family and other relationships) and professional practice (patient harm; loss of respect and trust from colleagues; loss of self-respect; suspension, probation or termination from the job; loss of income and seniority; and disciplinary action by the nursing board).

She listed the following common signs and symptoms of a substance abusing nurse:

• Increased tardiness and/or absenteeism;

• Frequent unexplained absences from the nursing unit;

• Work habits deteriorate;

• Erratic job history;

• Errors involving judgment;

• Mood swings;

• Medication and/or documentation errors;

• Failure to do narcotics count;

• Uses maximum prn dose for pain medications;

• Assigned patients complain of unrelieved pain;

• Sleepiness or hyperactivity;

• Offers to give medications for patients assigned to other nurses;

• Dishonesty;

• Isolates from co-workers;

• Unexplained need for money or borrowing money from co-workers;

• Suspicious attitude toward others; and

• Change in personal grooming.

Common physical signs and symptoms of a substance-abusing nurse include shakiness/tremors; fatigue; slurred speech; alcohol on breath or frequent use of mints, gum and mouthwash; diaphoresis; unsteady gait; runny nose; frequent mood changes; weight gain or loss; frequent nausea, vomiting and diarrhea; constricted/dilated pupils and change in personal grooming.

Nurses should follow the appropriate policies and procedures to report a suspected colleague to someone in a supervisory role, noted Cox.

“Reporting the colleague can be a positive step, protecting patient safety and supporting the colleague to enter necessary treatment,” she said.

According to the American Nurses Association Code of Ethics, Provision 3.6:

“Nurses must be vigilant to protect the patient, the public, and the profession from potential harm when a colleague’s practice, in any setting, appears to be impaired.”

“There is an ethical and legal responsibility to report if you feel a colleague is working while impaired,” Smith stated, remarking that nurses should never enable or “rescue” a colleague they suspect of substance abuse.

Though nurses may think they are helping by intervening and making excuses or covering for the impaired nurse instead of allowing them to accept the responsibility and consequences of their behaviors and actions, this allows the impaired nurse to be a continued risk to patients, themselves and others, she said.

Cox agreed. “If a nurse suspects substance abuse in a colleague, she should not ignore the incident, enable the colleague or lighten the suspected nurse’s load. The colleague should be reported immediately to prevent any future incidents,” she said.

Scott, the nurse whose ex-husband was reported for substance abuse, confessed to suspecting two different co-workers of using on the job. In both cases, the person acted different-“a little out of it, making simple errors that they normally wouldn’t be making,” she said. The one who was accused of stealing pain medication was constantly at the med cart and her patients took the maximum allowable amount of narcotics.

Because she was raised not to “tattle” on people, Scott said she would have gone to the person she suspected to talk about her suspicions.

But that was before substance abuse hit home; before Scott’s ex-husband told her the nurse who reported him saved his life.

“Now I know that the kindest thing to do is to report what I know,” she said, noting that, as the nature of the disease, an addict will lie, manipulate and do whatever possible to get out of being caught. If her suspicion is wrong, Scott said a good boss will keep the report anonymous.

“I’ve never met a recovering addict who wasn’t thankful for getting caught,” she concluded.

Beth Puliti is a frequent contributor to ADVANCE.