Ethics and Impaired Nurses

Running Head: ETHICS AND IMPAIRED NURSES1

Ethics and Impaired Nurses

Jill Collins, RN BSN

Washburn University

Emergency Department Charge Nurse

St. Francis Health Center

Topeka, KS 66606

December 14th, 2009

Running Head: ETHICS AND IMPAIRED NURSES1

Northeast Kansas ENA Chapter 447

Abstract

Impaired nursing practice is a very prominent issue faced by the nursing profession today. This issue can cause great moral distress for the nurse suspecting his/her coworker and/or friend of practicing impaired. The nurse often has to choose between protecting the patient and risking a friendship as well as causing detriment to his/her coworker by reporting him/her. The purpose of this article is to educate nurses on signs of impaired nursing practice and give a brief explanation of what drives a nurse to impairment. The article will also assist nurses in realizing that not only do nurses, as a profession, have an obligation to ensure the safety of the patients being cared for by impaired nurses but the profession also has an obligation to its peers to assist them in recovery and return to the workforce.

Running Head: ETHICS AND IMPAIRED NURSES1

Introduction

What would you do if you discovered or even suspected that you were working with a nurse that was impaired by either drugs or alcohol? Add to the equation the same nurse is either a close co-worker or a very good friend. It is a situation most nurses will probably find themselves in sooner or later. It is a situation which causes a great deal of moral distress which occurs when one faces a challenge about how to maintain his/her integrity or the integrity of the profession (Purtilo, 2005). Estimates suggest that approximately 20% of nurses are chemically dependent and working while impaired. That is 1 out of every 5 nurses. (Monroe, Pearson, & Kenaga, 2008) Many times recognizing the signs of an impaired nurse is a difficult task. This task becomes even more difficult when one considersfriendships, the fact nurses naturally want to help everyone and nurses tend to enable the behaviors at hand. One of the most difficult parts of suspecting impairment is deciding what to do with the information and how to handle the situation. This is the source of the moral distress. It requires either reporting the coworker putting his/her credibility, job and livelihood at risk or continuing to look the other way while putting patients’ lives at risk. It seems there should be a way, as a profession, we can report/confront our coworker in such a manner that it does not jeopardize his/her career and livelihood yet protects our patients from the potential effects of the impaired nurse.

Discussion

Impaired nursing practice is the inability of a nurse to perform essential functions of his/her job with reasonable skill or safety secondary to chemical dependency on drugs or alcohol, or due to mental illness (Dunn, 2005). The chemically dependent/impaired nurse may not necessarily be easy to recognize. Many times this nurse is very cheerful and outgoing, is willing to pick up hard to fill shifts, will volunteer to pick up medications from the pharmacy, and will volunteer to take those “difficult” patients who are in a lot of pain. Unless one recognizes these signs as being indicators of drug addiction, this nurse may be difficult to pick out. There are several other signs of drug and/or alcohol addiction which can include but are not limited to: requesting jobs in less supervised settings, volunteering to count narcotics, patients complaining of ineffective pain relief, frequent unwitnessed medication wasting, failing to obtain cosignatures, signing out more controlled substances than coworkers, frequent trips to the bathroom, increasing or unexplained tardiness or absenteeism, increased forgetfulness, showing up when not scheduled and around departmental drug supply, and gradual and subtle deterioration of routine work performance (Dunn, 2005), (Quinlan, 2003). One must also consider that “suspicion of substance dependency should not be presumed by a single sign or symptom, but rather by changes in behavior” (Quinlan, 2003). It is important for facilities to educate their staff on awareness of these symptoms.

One of the biggest questions surrounding impaired nurses is why and how one gets to the point of being addicted to drugs and/or alcohol so much so that one is willing to jeopardize his/her career, reputation, families and livelihood. There are several factors which are inherent to the occupation that contribute to dependency. Some of these factors are: demanding, high-pressure, stressful work environments, burnout, decreased staffing, overwork, sleep deprivation, increased workloads, mandatory overtime, and rotating shifts. Those nurses that work in critical care areas such as the ICU and ER also deal with: an unpredictable work pace, increased frequency of dealing with death, the immediacy of the nursing intervention, reliance on pharmocological agents, and ready access to controlled substances (Dunn, 2005). These factors all contribute to fatigue and stress which can ultimately lead to chemical dependancy. Other factors including family history, issues at home, financial difficulty, and simply the fact medications are readily available in the workplace and are seen as desireable methods to cure people also contribute to dependency and impairment (Dunn, 2005). It is rather easy to see how one could become chemically dependant.

There are many ethical principles surrounding the impaired nurse and the patient. The first principle to consider is nonmaleficence. Nonmaleficance considers one should “do no harm” as well as preventing harm, removing harm when it is being inflicted, and bringing about a positive good (Purtilo, 2005). According to this principle, it is a nurse’s duty to report an impaired coworker in order to prevent the potential harm he/she poses to patients when working under the influence of drugs or alcohol. This principle could also be applied to the impaired nurse. It is also our duty as a profession to help the impaired nurse with her addiction to prevent further harm to himself/herself.

The next principle is autonomy which is “the capacity to have the say-so about your own well-being” (Purtilo, 2005). One is certainly not granting the patient autonomy when he/she allows an impaired nurses to work with him/her. Most people would not willingly put their own lives in the hands of an impaired professional.

The third principle is that of veracity. It binds one to honesty and means one will tell the truth (Purtilo, 2005). In an ideal world, veracity should be inherent in all health professionals but unfortunatley it is not.

The principle of fidelity applies to both the patient and the nurse. It simply means that one will be faithful in meeting another’s reasonable expectations (Purtilo, 2005). Reporting impaired nurses and taking them out of active practice is being faithful to society, but as a profession, nursesshould also keep in mind that they should be faithful to our colleagues in helping them through a very difficult time. The primary concern of nurses should be the patients that they care for. Afterall, why do nurses get into this profession and why is there even such a profession to begin with? It is because people need to be cared for and nurses have made the choice to do so. The American Nurses’ Association’s (ANA) code of ethics states “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” and “the nurse’s primary commitment is to the patient, whether an individual, family, group, or community” (American Nurses Association, 2001). It is expected of the profession to uphold these standards and not doing so can also have legal ramifications. Any nurse who is aware of or suspects impaired nursing practice and fails to report it to the proper authorities can be charged with negligence if a patient has a bad outcome. It is imperative to report suspicion of impaired nursing practice for the protection of our patients. But what about the impaired nurse?

The ANA also states “nurses in all roles should advocate for colleagues whose job performance may be impaired to ensure that they receive appropriate assistance, treatment and access to fair institutional and legal processes. This includes supporting the return to practice of the individual who has sought assistance and is ready to resume professional duties” (American Nurses Association, 2001). Part of advocating for a colleague is helping him/her to realize he/she has a problem and he/sheneeds help. “Nurses should understand that if addicted nurses are not helped, they are in danger of harming patients, the facility’s reputation, the nursing profession, and themselves” (Dunn, 2005). Unfortunately, many times when the discovery has been made by an institution that it has an impaired nurse working there, the nurse is immediately terminated which begins its own vicious cycle. The nurse obviously would not want shared with his/her colleagues why he/she was terminated and so management has an obligation to uphold the nurse’s confidentiality. This makes it nearly impossible for any coworker or friend to approach the nurse about her problem and offer to help. The nurse’s healthcare benefits are also ceased at this time leaving him/her no coverage to seek help. The nurse then either seeks employment elsewhere and is placed back in a position where he/she is able to continue impaired practice or seeks other alternatives which may include suicide attempts since he/she feels hopeless.

In an attempt to prevent the above mentioned scenario, the National Nurses Society on Addictions, and the American Nurses Association have encouraged state nursing boards to adopt an alternative-to-discipline program. (Monroe, Pearson, & Kenaga, 2008) These programs encourage each state to adopt non-punitive strategies to address the disease of chemical dependency (Monroe, Pearson, & Kenaga, 2008). The hope would be that once the impaired nurse has been discovered, he/she would be put on a leave of absence and put into a treatment program with the ultimate goal being the ability of the nurse to return to work in the nursing field.

Conclusion

Confronting or reporting a nurse that one suspects of being impaired is a source of great moral distress. It is quite hard to choose sometimes between doing what one knows is ultimately the right thing to do or potentially causing great turmoil in the life of a friend and fellow nurse. It is, however, a necessary step to take. Not only are nurses protecting patients from potential harm, but in the long run the are helping the impaired nurse as well. It is in the best interest of the nursing profession to advocate for both the patient and the impaired nurse.

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