Running head: SUBSTANCE ABUSE

Changing Substance Abuse in Nursing

Taylor A. Polk
USCA School of Nursing
November 17, 2014

On my honor as a USCA student I have completed my work according to the principle of

Academic Integrity. I have neither given nor received any unauthorized aid on this
assignment/examination.
___________________________

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Name

Date

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Changing Substance Abuse in Nursing

Substance abuse is a dangerous and complex issue. Many people, influenced by various
reasons, abuse alcohol and drugs. People are battling substance abuse in all occupations,
including nursing. Substance abuse in nursing is a leadership/management issue that influences
health care delivery (Quinlan, 2003). It poses a great threat, not only to nurses, but to the
community. Patients cared for by impaired nurses are at great risk. Nurses are responsible for the
care and wellbeing of their patients. The impaired nurse is not able to provide safe patient care,
and he/she is not in complete control of the care provided. Nurse leaders and managers are
needed to bring more attention to this issue, facilitate change, and hopefully decrease substance
abuse in nursing.
As a potential nurse leader or manager, the issue of substance abuse in nursing is
concerning, but also thought-provoking. This issue is interesting and meaningful to me because
so many people are affected by substance abuse, either indirectly or directly, and it remains a
long-standing issue. Substance abuse treatment is not only a personal matter, like many believe.
The treatment requires support, time, and commitment in order to be successful. Substance abuse
is a complex issue, but resolution is possible with a supportive and treatment centered approach.
When others become knowledgeable and aware of substance abuse, progress can be made
(Monroe, Pearson, & Kenaga, 2008).
Review of Literature
The review of the topic, substance abuse in nursing, in relevant literature thoroughly
explains the significance of this problem. Monroe et. al. (2008) discuss that substance abuse is
more prevalent in nursing because of the accessibility of controlled substances. It was estimated
that the nursing population affected by substance addiction is around 20%. They also explain that

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substance abuse is not a new problem. It was recognized as a problem in the early 1900s, and is
still considered a major problem today (Monroe et al., 2008).
In order to understand why this issue has continued to be an area of concern, precipitating
factors need to be distinguished. Quinlan (2003) suggests that mental health disturbances can
play a role in substance abuse. Other personal, physical, and emotional problems can lead to
substance abuse, like pain or death of a significant other (Monroe & Kenaga, 2010; Quinlan,
2003). Another factor associated with substance abuse in nursing is ineffective regulation by
organizations. A lack of superior enforcement decreases the trust in the employees superiors to
take action against risky nursing behavior, leading to more impaired nurses treating patients
(Frone & Trinidad, 2012). Even when superior enforcement is adequate, superiors might lack the
knowledge necessary to notice an impaired nurse or be unaware of treatment options. Substance
use behaviors, declining work performance, and altered co-worker relationships go unnoticed, or
are many times blamed on everyday stressors. Lack of knowledge is not the only reason
substance use goes unnoticed. Many impaired nurses perform effectively on the job, making it
difficult to detect them (Quinlan, 2003).
The literature also identified fear as a major threat to reporting impaired nurses, whether
it be self-reported or colleague-reported. The impaired nurse is fearful of punishment and losing
his/her job (Monroe & Kenaga, 2010). The unknown long term effects of confessing is fear
provoking. When treatment, recovery, and job security is not guaranteed, the option to
acknowledge the problems seems too risky (Monroe et al., 2008). Quinlan (2003) explains that
colleagues are not just apprehensive to report for the same reasons as the impaired nurse, but also
fear that by acknowledging one nurse as a substance abuser, it will reflect on all nurses. Quinlan
(2003) refers to this as white coat (p. 150) syndrome.

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Many actions have been taken to combat the issues regarding substance abuse in nursing.
Mandatory reporting and drug testing is a foundational way to decrease substance abuse in
employees (Quinlan, 2003). The American Nurses Association (ANA) first challenged this
nursing problem in 1982, by supporting the use of treatment options before punishment (Monroe
et al., 2008). Then, in 2002 the ANA further pledged its commitment to alternative-todiscipline programs (Monroe et al., 2008, p. 156) by urging all states to adopt these programs
(Monroe et al., 2008).
Although these and many other actions have been taken to ultimately eliminate substance
abuse in nursing, the problem still persists, and solutions need to be determined. The solutions to
the problem are divided between two main categories, alternative-to-discipline programs and
discipline programs. Six states in the United States are using disciplinary programs, as of 2008
(Monroe et al., 2008). Even though this is only a small fraction of the states, Monroe et al.
(2008) explain that disciplinary programs are not effective at resolving the issue because it only
focuses on one aspect of the problem. The focus is targeted at prevention of patient harm.
Disciplinary programs ensure prevention by putting the impaired nurse on probation, on
suspension, or revoking the nurses license. This approach lacks the advocacy needed for
impaired nurses to get long-term treatment and return to work, which sets the impaired nurse up
for vocational and financial failure (Monroe et al., 2008).
Alternative-to-discipline programs are the more supported and effective solution to
substance abuse in nursing. This program is very broad and differs from state to state, but all
programs focus on treatment, not discipline. Many different treatment options and recovery
efforts are implemented in alternative-to-discipline programs, including inpatient treatment and
monitored aftercare (Monroe et al., 2008). Alternative-to-discipline programs are intended to

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prevent the negative outcomes of reporting for the impaired nurse, like job insecurity (Monroe et
al., 2008). Another solution is improved supervisor enforcement (Frone & Trinidad, 2012).
Frone and Trinidads (2012) research found that supervisor enforcement is negatively related to
illicit drug use on and off-the-job and negatively related to alcohol use on-the-job. Supervisors
that possess the skills to recognize and act against drug and alcohol problems, have the ability to
improve substance abuse in nursing (Frone & Trinidad, 2012).
I believe that the solution to the issue, substance abuse in nursing, is not easily resolved.
Resolution does not seem possible with just one of the solutions discussed. If the most effective
aspects of each solution are combined, the issue can be improved. The first step to improve the
problem would need to be knowledge and recognition of the problem, with greater supervisor
enforcement (Frone & Trinidad, 2012). By taking this step, the problems significance can be
better understood, and reporting would increase. Then, once the problem is discovered, an
alternative-to-discipline program needs to be implemented. This would give the impaired nurse
the resources needed to better himself/herself. If the impaired nurse refuses or is not compliant
with the treatment, disciplinary action should be taken. This would assure patient safety, by not
allowing an impaired nurse to provide care (Monroe et al., 2008). A disadvantage of this solution
is the risk for bias, related to the preconceptions of substance abuse. This risk makes it difficult
to assure impartial treatment to all impaired nurses. Another disadvantage is the states lack of
treatment uniformity. Alternative-to-discipline programs are not adopted by all states, and the
states who have adopted this program differ in treatment options. Lack of uniformity would lead
to uncertainty of the best practice (Monroe et al., 2008). Uncertainty of the parameters for
disciplinary action is an additional disadvantage. The actions and behaviors that signify the need
for disciplinary action would need to be outlined, along with time restraints.

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Planning

Since change is such a difficult and complicated process, change theories can be a useful
aid. As a nurse manager, I would use Kurt Lewins change theory to integrate a change in
education, recognition, and treatment of substance abuse for nurses on my unit (as cited in
Marquis & Huston, 2012). The circumstances surrounding substance abuse, like the fear
associated with acknowledgement of the abuse, make this change especially difficult (Monroe &
Kenaga, 2010). By advancing through the unfreezing, movement, and refreezing phases of Kurt
Lewins theory, thorough integration of this change can be achieved.
The main objective during the unfreezing phase is to elicit a concern and want for change
in the nursing staff. This can be accomplished by educating the staff. Learning the prevalence of
substance abuse in nursing will communicate the significance of the problem (Marquis &
Huston, 2012). The staff also need to be aware that this is not only a problem for the substance
abuser, but can also become problematic for each nurse on the unit. Some states have mandatory
reporting, with adjunct responsibility for patient harm (Quinlan, 2003). In order to plan and
implement the change, during the movement phase, driving forces need to be greater than
restraining forces. There are many barriers to the proposed change, but by planning to slowly
integrate the change, it will be more achievable. During the last phase, refreezing, I would need
to plan to participate throughout the changing process. This would mean assessing how well the
transition is progressing and resolving any problems that arise (Marquis & Huston, 2012).
In order to evaluate if Kurt Lewins theory has guided my planned change into the status
quo, objectives with measurable criteria need to be set. I would carry out a thirty question unit
survey, evaluating the staffs understanding and concern about the problem. The survey would
be given before and after education, in order to assess the impact of the education on the staff.

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Numeric values would be placed on each answer in order to systematically evaluate the
responses. A unit wide performance appraisal would also help evaluate the change. Like the unit
survey, I would first appraise the staff before any plans are put into action. The initial
performance appraisal would be simplified, including one-on-one interviews and observations.
After the change has been accepted and integrated into practice, I would organize another
performance appraisal of the staff. This appraisal would evaluate not only the basic nursing
duties, required of the nurses, but would also include criteria specific to the use of strategies to
recognize and treat impaired nurses. The appraisal would include one-on-one interviews,
observations, co-workers input, and patient satisfaction. There would be many criteria,
accommodating for the various responses, holding distinct weights (Marquis & Huston, 2012).
Implementation
Although planning and preparing for the steps needed to coordinate a planned change is
imperative, classical change strategies need to be applied to implement the action plan. The
rational-empirical change strategy would be useful (Marquis & Huston, 2012). With the evidence
revealing the longevity of substance abuse in nursing, despite the harmful effects, lack of
knowledge must play a role (Monroe et al., 2008). Using this strategy, it would be assumed that
with increased knowledge of the significance of the problem, along with ways to recognize and
treat impaired nurses, the staff will be more accepting of the change. I would hold mandatory
classes, hold optional classes, make current evidence-based research available, and allow
opportunities for research (Marquis & Huston, 2012).
The normative-reductive change strategy would also be beneficial while implementing
this change (Marquis & Huston, 2012). As the review of relevant literature revealed, fear and
shame are major restraining forces towards acknowledging and offering help to impaired nurses

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(Quinlan, 2003). The implementation of this strategy would empower the more reluctant staff to
integrate this change, by using group norms and peer pressure to socialize and influence
(Marquis & Huston, 2012, p. 168) them. To apply this strategy into the action plan, I would first
select the staff member holding the most influence over the other staff. This could be done by
simply observing the staff, or by judging the leadership qualities of each staff member. After
choosing the staff member, hopefully he/she would be willing to be the leader in this change.
Having a respected leader for the changing process will influence the other staff to be more
accepting and eager to change (Marquis & Huston, 2012).
Education and recognition can be done without many obstacles, but fair and effective
treatment is more difficult to insure. Depending on the state, the treatment options can be
different (Monroe et al., 2008). Since my action plan is to have alternative-to-discipline
treatment options for the impaired nurse, supported by evidence-based research, I would have to
advocate for my staff. This can be accomplished by doing a more complex review of relevant
literature, or by organizing research of my own. Once I have the supporting evidence, I can
communicate with the nursing supervisor and the organizations leaders to bring awareness and
encourage action.
Evaluation
To determine the success or failure of my action plan, I would first compare the results of
the two surveys, measuring knowledge and awareness of substance abuse in nursing. As the
nurse manager, I would conduct the two surveys and the evaluation. The surveys will take place
a week before the education classes and five months after the education classes. Each response
would correlate to a number from one to five, one being strongly disagree and five being
strongly agree. Depending on the question, a response of one could hold a value of five or a

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response of five could hold a value of five. Each staff member would be grouped into the
strongly knowledgeable and aware, the moderately knowledgeable and aware, and the weakly
knowledgeable and aware group for the initial and final survey. The strongly knowledgeable and
aware group would consist of staff members whose responses added up to 120-150. The
moderately knowledgeable and aware group would consist of staff members whose responses
added up to 90. The weakly knowledgeable and aware group would consist of staff members
whose responses added up to 30-60. After grouping all of the staff members, I would analyze the
differences between the initial and final survey within a week after the final survey. A staff
increase of more than 5% in the strongly knowledgeable and aware groups would be considered
significant, but a staff increase of 50% in the strongly knowledgeable group would be deemed a
success.
The performance appraisals also needs to be evaluated. I, the nurse manager, would
conduct all elements of the performance appraisal. I would start the initial performance appraisal
two months in advance, in order to observe the staff over a period of time. At the end of the two
month observation, I would hold a one-on-one interview with each staff member. In order to
manage time appropriately, each staff member could complete the initial survey at the end of the
interview. A week after the initial survey and interview the education classes will begin. Over a
five month period, following the classes, I will observe the staff members and obtain five
random patient evaluations on each staff member. After the five month observation period, I will
conduct the final one-on-one interview and survey, along with co-workers appraisals of each
other. The performance appraisals would be evaluated by comparing the staffs interview
responses and observed actions, along with co-worker and patient responses to a series of
standardized objectives. Each objective holds a distinct weight, depending on the complexity,

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totaling to a 100%. The number of met objectives would determine each staffs ability to
recognize and assist an impaired nurse. A score of 90-100% would demonstrate strong ability. A
score of 75-90% would demonstrate moderate ability. A score of 75% or below would
demonstrate weak ability. After grouping each staff member in the strong, moderate, and weak
groups, I would compare the initial and final appraisals within a week after the final appraisal.
Like the surveys, a staff increase of 5% in the strong group would be considered significant, but
a staff increase of 50% in the strong group would be deemed a success.
Conclusion
Substance abuse in nursing poses a great risk to patients health and wellbeing. Nursing
leaders and managers are needed to combat this issue. With nursing leaders and managers
guiding a change in knowledge, awareness, and treatment of substance abuse in nursing, patient
care and treatment of impaired nurses can be improved.

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References

Frone, M. R., & Trinidad, J. R. (2012). Relation of superior social control to employee substance
use: Considering the dimensionality of social control, temporal context of substance use,
and substance legality. Journal of Studies on Alcohol and Drugs, 73, 303-310. Retrieved
from www.jsad.com
Marquis, B. L., & Huston, C. J. (2012). Leadership roles and management functions in nursing:
Theory and application (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Monroe, T., & Kenaga, H. (2010). Dont ask dont tell: Substance abuse and addiction among
nurses. Journal of Clinical Nursing, 20, 504-509. doi:10.1111/j.1365-2702.2010.03518.x
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, 156-161. doi:10.1080/10884600802306024
Quinlan, D. (2003). Impaired nursing practice: A national perspective on peer assistance in the
U.S. Journal of Addictions Nursing, 14, 149-155. doi:10.1080/10884600390245749