{ chemical dependency & drug diversion in nursing presented by nathan buchinger, rn, ccrn
TRANSCRIPT
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Chemical Dependency & Drug Diversion in Nursing
Presented by Nathan Buchinger, RN, CCRN
Objectives• To understand the prevalence of nurses who practice
while under the influence of drugs or alcohol• To understand the importance of reporting suspicious
behavior• To examine the efficacy of punitive and non-punitive
approaches to chemically dependency in health care• To examine theories and assumptions regarding nurses
and drug dependency• To understand what current evidence-based research
states about this issue
Chemical DependencyDefinition:
: A physical or psychological habituation to a mood- or mind-altering drug, such as alcohol or cocaine
*Chemical Dependency. (2007). The American Heritage Medical Dictionary. Retrieved from http://medical-dictionary.thefreedictionary.com/chemical+dependency
Addiction noun \ə-ˈdik-shən, a-\
: compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly : persistent compulsive use of a substance known by the user to be harmful
*Addiction. (n.d.). Merriam-Webster’s online dictionary. Retrieved from http://www.merriam- webster.com/dictionary/addiction
Drug DiversionDefinition:
“The transfer of a prescription drug from a lawful to an unlawful channel of distribution or use” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 2).
“Theft, forgery, or alteration of prescriptions by health care workers” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 2).
Drug diversion is illegal!
Prevalence
Previous estimates: 1 in 5 nurses practice while impaired (Griffith, 1999)
Most current estimate: About 1 in 10 (Dunn, 2005)
Rate of drug addiction in the US: 1 in 10 (Dunn, 2005)
Relevance to Nursing
ANA Standards of Care
Standard 7: Ethics“Delivers care in a manner that preserves and protects healthcare consumer autonomy, dignity, rights, values and beliefs” (ANA, 2010, p. 47)
Standard 10: Quality of Practice“Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner” (ANA, 2010, p. 52)
Standard 11: Communication“Conveys information to … others in communication formats that promote accuracy” (ANA, 2010, p. 54)
Standard 16: Environmental Health“Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers” (ANA, 2010, p. 61)
Patient RightsHigh Quality Patient Care
“[Nurses] first priority is to provide you the care you need, when you need it, with skill, compassion, and respect” (AHA, 2003, p. 2)
A Clean and Safe Environment
“[Nurses] use special procedures to avoid mistakes in your care and keep you free from abuse and neglect” (AHA, 2003, p. 3)
Root Cause Analysis
Problem
Causes:
Chemical Dependency
Unmet needsThreats to personal/social identityStressBurnoutSocioeconomic factorsComorbid physical/mental problemsChronic Pain
Relevant Nursing Theories
• Erickson’s Modeling and Role Modeling Theory:• “All people want to be the best that they can possibly be;
unmet basic needs interfere with holistic growth whereas satisfied needs promote growth” (Erickson, Tomlin, & Swain, 2002, p. 56).
• “Object loss results in basic need deficits” (Erickson, Tomlin, & Swain, 2002, p. 88).
• Barker’s Tidal Model of Mental Health Recovery:• “People who experience any of the myriad threats to their
personal or social identities, commonly called mental illness or mental health problems, experience a human threat that renders them vulnerable” (Barker, 2003, p. 6-7).
Theories of Drug Use• Three Main Categories of Causation Theories:
• Biological: Innate physical mechanism• Genetic• Metabolic Imbalance
• Psychological: Compulsion & continued use• Positive/Negative Reinforcement• Pleasure seeking• Inadequate Personality Theory• Risk taking behaviorism
• Sociological: Individual within society
Commonly Abused Drugs
• Opioids• Vicodin• Percocet• Oxycontin• Morphine• Methadone• Fentanyl• Codeine• Dilaudid• Demerol
• Barbiturates• Amytal• Phenobarbital• Seconal
• Benzodiazepines• Ativan• Xanax• Librium• Valium• Halcion• Restoril
• Sleep Meds• Ambien• Sonata• Lunesta
• Amphetamines• Adderall• Dexedrine• Biphetamine
• Propofol
Signs of Impairment• Attendance
• Excessive call-ins & tardies
• Frequent trips to the restroom
• Long or frequent breaks• Early arrival or late
departure• Performance
• Assignments require more effort/time
• Absentmindedness• Carelessness• Complaints regarding
poor care• Behavior
• Poor hygiene• Mood swings/irritability• Poor recall
• Handling of Controlled Substances• Frequent med errors• Unwitnessed/Excessive
wastes• Frequents spills/drops• Patient complaints of not
receiving documented meds• Use of infrequent drugs
• Physical signs• Tremors• Nervousness• Alcohol odor• Slurred speech• Unsteady gait• Excessive use of breath
mints• Unusual fatigue• Blackouts
Roles in Reporting• Floor Nurses
• Know the signs• Ethical duty to report• Confront when patients are
at risk• Go to manager right away
• Charge Nurses• Same as floor nurses• Do not ignore• Do not lighten the
assignment• Do not accept excuses
• Nurse Managers• Same as above• Explain to nurse
observations made• Listen to their side in
private• Report to next in chain of
command• Document everything in
writing
• Administrators• Follow hospital protocol• Perform investigation• Gather all relevant data• Meet with the impaired
nurse, Human Resources, and nurse manager
• Apply corrective action• Report to State Board of
Nursing • Follow-up
Alternative-to-Discipline Programs
• Four Tenets of ATD Programs• Assistance is better than discipline• Self-regulation• Swift removal of impaired nurses
from work place• Workplace safety promotion
Reinstatement
Safety Recommendations
• Know the signs of impairment
• Know who to report to & what to report
• Truly witness wastes• Know your role• Only reinstate
compliant, rehabilitated nurses
• Random drug testing?
• QSEN Competencies• Patient-centered
care• Teamwork and
collaboration• Safety• Quality• Evidence-based
practice
For Further Study
“Good Medicine, Bad Behavior: Drug Diversion in America”
http://www.goodmedicinebadbehavior.org/explore/pain_management.html
References• Earley, P. H., & Finver, T. (2013). Addiction to propofol: A study of 22
treatment cases. Journal of Addiction Medicine, 7(3), 169-176. doi:10.1097/ADM.0b013e3182872901
• Inciardi, J. A., Surratt, H. L., Lugo, Y., & Cicero, T. J. (2007). The diversion of prescription opioid analgesics. Law Enforcement Executive Forum, 7(7), 1–14.
• Monroe, T., Pearson, F., & Kenaga, H. (2008). Procedures for handling cases of substance abuse among nurses: A comparison of disciplinary and alternative programs. Journal of Addictions Nursing, 19(3), 156-161. doi: 10.1080/10884600802306024
• Monroe, T., & Pearson, F. (2009). Treating nurses and student nurses with chemical dependency: Revising policy in the United States for the 21st Century. International Journal of Mental Health & Addiction, 7(4), 530-540. doi:10.1007/s11469-009-9208-2
• Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20(3-4), 504-509. doi: 10.1111/j.1365-2702.2010.03518.x
• Monroe, T. B., Kenaga, H., Dietrich, M. S., Carter, M. A., & Cowan, R. L. (2013). The prevalence of employed nurses identified or enrolled in substance use monitoring programs. Nursing Research, 62(1), 10-15. doi: 10.1097/NNR.0b013e31826ba3ca
• Wright, E. L., McGuiness, T., Moneyham, L. D., Schumacher, J. E., Zwerling, A., & Stullenbarger, N. E. (2012). Opioid abuse among nurse anesthetists and anesthesiologists. AANA Journal, 80(2), 120-128.
References (cont.)• Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and
their work (7th ed.). Maryland Heights, MO: Mosby Elsevier.• American Hospital Association. (2003). The patient care
partnership: Understanding expectations, rights and responsibilities [PDF document]. Retrieved from http://www.aha.org/content/00-10/pcp_english_030730.pdf
• Barker, P. J. (2003). Psychiatric and mental health nursing: The craft of caring. London: Arnold.
• Erickson, H. C., Tomlin, E. M., & Swain, M. A. (2002). Modeling and role-modeling: A theory and paradigm for nursing. Cedar Park, TX: Est. Co.
• Manchikanti, L., Fellows, B., Ailinani, H., & Pampati, V. (2010). Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician, 13(5), 401-435.
• Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., Pampati, V., Grider, J. S., & Boswell, M. V. (2012). Opioid epidemic in the United States. Pain Physician, 15(3), ES 9-38.
• Quality and Safety Education for Nurses Institute. (n.d.). Competencies. Retrieved from http://qsen.org/competencies/