Do you work with an impaired nurse? ED nurses are at higher risk

Drug, alcohol abuse are more common than most believe

When an emergency nurse at Loma Linda (CA) University Medical Center and Children’s Hospital turned white as a ghost, broke into a sweat, and nearly passed out, she claimed to be suffering from a bad flu.

"Everyone accepted that explanation," says Jill Pollock, RN, executive director for critical care and emergency services nursing at Loma Linda. "Later, it became obvious the nurse had a substance abuse problem."

Working in the ED puts you at high risk for substance abuse, emphasizes Pollock.

"We are in a very stressful, chaotic environment on a continual basis. Part of wanting to alter your mood when you’re addicted is about escaping," she explains. "Also, we are a helping profession; but when we’re the ones who are hurting, we don’t know how to take care of ourselves."

Denial is rampant when it comes to substance abuse, says Pollock. "Nurses tell themselves, I’m a nurse and a professional, and it would never happen to me. I can self-medicate and still be OK,’" she explains. "Also, we have easy access to medication. When we’re exhausted from working double shifts, we may feel we need to take something to keep us going."

Estimates about impaired nurses reveal the problem is significant, says Valerie Murchake Wright, RN, MLHR, alternative program coordinator for the Ohio Board of Nursing in Columbus. "Based on estimates, we believe that 15% of nurses will have a drug problem at some point in their career. Chances are very good you are currently working with somebody who has a problem." (See story on the latest substance abuse statistics, p. 83.)

A recent study shows that ED nurses were three to five times more likely to use marijuana or cocaine, when compared with nurses in women’s health, pediatrics, and general practice.1 "The literature shows that drug use in nurses is at least as high as in the general population," Wright reports.

Here are some things to consider when confronting substance abuse in your ED:

Don’t subscribe to stereotypes.

Although attitudes are changing, there is still a serious misconception about substance abuse, says Pollock.

"There is an ongoing conflict as to whether substance abuse is a deviant behavior or an actual illness. It is a true illness, but as health care professionals, it’s difficult to understand how this could happen to one of our colleagues," she explains. "We ask ourselves, How on earth could a nurse who is a caregiver and promotes health harm themselves?’ That is unthinkable."

The impaired nurse doesn’t usually fit the stereotype of an alcoholic or drug addict, Pollock emphasizes. "It’s usually not the nurses who you may first suspect," she says. "Substance abusers are often bright, well-liked, hard working, skilled practitioners."

Know the realities of loss of license.

The penalties for substance abuse aren’t necessarily as severe as the impaired nurse believes, stresses Liz Jazwiec, RN, a Crestwood, IL-based consultant specializing in staffing issues.

"The myth is that if you’re caught taking drugs as a health care worker, you lose your license automatically," Jazwiec says. "But in most cases, you won’t lose your license if you take care of the problem and get treated." (See story on alternative programs, p. 83.)

Penalties may be minimal as long as the problem is caught early, explains Jazwiec. "With substance abuse, nurses are usually given the opportunity to recover. But if it goes unchecked or causes some grave consequences such as a bad outcome with a patient, then you can lose your job and your license," she says. "It’s almost doing the nurse a favor if you point it out early."

Unfortunately, most impaired nurses don’t get help until after they are fired, Jazwiec notes. "Until it gets to that point, the nurse doesn’t get help, and things progress and it becomes a point of no return," she says. "Once the decision is made to terminate, they may get help and start fresh somewhere else."

Ignoring the problem is not doing an impaired nurse any favor, argues Jazwiec. "When a problem goes to the extreme, it can have sad and tragic consequences, such as losing jobs or losing lives," she explains. (See related story and guest column on steps to take when you suspect an impaired colleague, p. 79 and p. 85.)

If the nurse’s drug problem harms a patient, there can also be serious legal ramifications for the hospital, Jazwiec notes.

Avoid burnout.

"ED nurses have a high potential for burnout because they are working with trauma all the time, both psychological and physical. So they can become traumatized themselves," says Madeline Naegle, RN, CS, PhD, FAAN, associate professor at the division of nursing at New York University in New York City. "There is a strong connection between psychological trauma and substance abuse."

ED nurses need to nurture themselves, stresses Naegle. "You have to practice very good self care. That includes taking vacation time when you have it, relaxation, exercise, socializing, and hobbies," she says. "In the ED, you are constantly assaulted psychologically by upsetting events. So you need to find ways to refresh yourself and relieve the psychological strain."

Never use alcohol or drugs to medicate bad feelings, such as fatigue or feeling upset, says Naegle. "That sets up a pattern of malfunctional use which can get you into trouble," she warns.

Follow policies and procedures.

Make sure department policies for keeping track of controlled substances are closely followed, Wright advises.

"If you have an ED where no one is following the rules, it’s easier to steal drugs," says Wright. "That is the one area where the ED is more at risk than other departments. It’s so hectic, the patients are in and out, and it may be more lax in how closely policies are followed."

Watch for warning signs in yourself.

The following signs could mean you are developing an alcohol abuse problem, says Naegle:
— You are drinking more frequently.
— You find yourself looking forward to drinking.
— You consistently find yourself drinking more than you intended to.
— You mix alcohol with prescription drugs or marijuana.
— You drink more than five drinks in the course of an evening once a week or more.

Because ED nurses are at high risk for prescription drug abuse, it’s important to closely monitor yourself for warning signs, recommends Naegle. "If you overuse prescription drugs, use them in ways they weren’t intended, are self-medicating with a controlled substance, or using a controlled substance for an extended period of time without being evaluated by your care provider, you could be developing a problem," she warns.

Utilize state and national resources.

"It’s important that you use the resources of nursing specialty organizations and state organizations in addressing the problem of substance abuse," says Naegle. "However, people with a substance abuse problem are often very isolated and are not joiners, so they may not be members of any organization."

State nursing organizations also will help nonmembers, Naegle notes. "You can provide anonymous information, and they will give you a referral to contact," she says.

The state association is separate from the state Board of Nursing, Naegle points out. "Your professional organization is not required to report people with drug or alcohol problems," she says. "In addition, many states have diversion legislation which allows you to surrender your license voluntarily while in treatment and get it back when you get well."


1. Trinkoff A, Storr C. Substance use among nurses: Differences between specialties. Am J Pub Health 1998; 88:581-585.