RUNNING HEAD: PORTFOLIO III
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Portfolio III
Sara Voigtritter
Jennifer Lillibridge
Nursing 309P
May 27, 2012
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Impaired Nursing Practice
Impaired nursing practice is an issue that affects patient safety. It is estimated that the rate
of substance abuse in the nursing population is similar to the general population and is as high as
ten percent, with six percent impaired to the point that it interferes with their ability to care for
patients. Impaired nurses tend to use prescription medication at a higher rate than the general
population, and tend to use cocaine and marijuana at a lower rate than the general population
(Dunn, 2005).
Signs and symptoms of the impaired nurse apparent to management include: excessive
numbers of sick days or absences without notification, frequent disappearances, long trips to the
bathroom, excessive amount of time spent near drug dispensation site, volunteering for overtime
or showing up when not scheduled to work, coming to work early and staying late without
apparent reason, unreliability with appointments or deadline. On the job the impaired nurse may
show confusion or difficulty concentrating on tasks, difficulty accepting blame, increased
wasting of medications, breakage or spilling of drugs often, volunteering to administer other
nurses’ controlled medications, usage of maximum amount of PRN medication dosages, and be
increasingly defensive about medication errors. Physical changes that colleagues may notice
include: deterioration of personal hygiene and appearance, inappropriate wearing of long sleeves,
personality changes, pinpoint pupils, shaking hands, unsteady gait, slowed down or slurred
speech, and increased energy. The nurse’s patients may complain that pain medications
dispensed by the nurse are not working. The nurse may begin to isolate from the rest of the unit
but taking breaks alone and avoiding staff get-togethers (DeClerk, 2008).
Risk Factors
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Risk factors for substance abuse include family history of mental disorders, emotional
abuse or impairment, alcoholism, and/or drug abuse. Personal risk factors for substance abuse
include low self-esteem, psychological or physical pain, complex personal emotional problems,
history of sexual trauma, overachievement, chronic overwork, previous mental health problems,
and a work environment that is high-pressure, demanding, and stressful. Nurses and other
people in service professions tend to come from families with a higher incidence of substance
abuse than the general population, with one study showing the percentage of nurses who have at
least one family member who is an alcoholic as eighty percent. It has been proposed that
substance abuse may be a way to cope with increased workloads, rotation of day and night shifts,
floating to unfamiliar work environments, and stressful shifts that contribute to an increased
sense of isolation, fatigue, and immense stress (Dunn, 2005).
Some studies have shown that nurses who have exposure to death and dying, more
demanding jobs with a higher rate of burnout, and lack of education regarding substance abuse
are at higher risk for substance abuse. Nurses who work in the intensive care unit (ICU),
emergency room (ER), operating room (OR), postanesthesia care unit (PACU), and oncology
tend to have easier access to drugs and higher rates of substance abuse, especially binge
drinking. Psychiatric nurses may be more likely to abuse prescription medication because they
see it as an acceptable form of self-treatment (Dunn, 2005).
Another obvious, but ever present risk factor for nurses is the constant access to and
availability of medications in the workplace. Nurses, who are trained to alleviate symptoms in
patients with medications may be more inclined to treat symptoms in themselves by selfmedicating. Familiarity with controlled substances may also increase nurses’ comfort with the
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substance and increase the chance that the nurse may try the substance themselves to attempt to
treat their own symptoms (Dunn, 2005).
Treatment Options
The first step in treatment is identification. Once management has identified a nurse in
need of intercession through peer reports or the nurse not meeting a department-specific
minimum level of care, the manager should select a private place with information regarding
available assistance such as employee assistance programs, let the nurse know about available
treatment programs, and disciplinary action that will follow if the nurse does not comply with the
recommendations discussed in the meeting. A therapist or social worker may be used to facilitate
the meeting and educate the members of the intercession team about alcoholism and addiction. If
the state has a mandated reporting law, the nurse will be reported to the board. In the case of
California, nurses are only reported to the board if they do not successfully complete the
diversion program (California Board of Registered Nursing, 2012; Dunn, 2005).
Once nurses identify themselves or their organizations identify them as in need of
chemical dependency treatment, they may be eligible for a diversion program such as the one
offered by the California Board of Registered Nursing (BRN). Nurses who are licensed by the
state of California and live in California who use substances to the extent that it can affect their
practice and voluntarily commit to the diversion program are able to circumvent the normal
disciplinary process and obtain help (California Board of Registered Nursing, 2012).
Treatment programs available to nurses include: detoxification centers, education, drug
screening, coping skills training, self-help recover, twelve step programs such as Alcoholics
Anonymous or Narcotics Anonymous, and education programs. Random drug tests should be
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performed for at least a year, aftercare and counseling should be attended, and the employee
should sign a commitment to remain drug and alcohol free (Dunn, 2005).
California requires that nurses attend counseling (no less than every three months and no
more than weekly) and that nurses attend a six month long board-approved rehabilitation
program. The nurse must also attend at least one Alcoholics Anonymous or Narcotics
Anonymous meeting and have paperwork signed to that effect. In addition, unless they are part
of legally documented medical treatment, the nurse must abstain from all mood-altering
medications as part of the diversion process. In addition nurses must comply with mandatory
random drug tests, physical examinations, attend facilitated support group meetings, and attend
counseling or therapy sessions as determined necessary by the BRN (California Board of
Registered Nursing, 2011).
Re-Entry into Practice
Once the nurse has demonstrated that he or she is active in recovery and has a minimum
of twenty-four months of clean random tests of bodily fluid, he or she can begin re-entry into
practice (California Board of Registered Nursing, 2012). The nurse should sign a letter of
commitment to stay drug and alcohol free. Nurses should remain out of work for at least six to
twelve months during treatment, and that the nurse should be placed in a clinical setting in which
he or she does not have access to his or her drug of choice, has a less-stressful workload, limited
work hours (no overtime or night shifts) in a structured environment, and be willing to submit to
random, supervised drug screenings while working. Return-to-work agreements need to be
specific and outline the steps the nurse needs to take to ensure that his or her recovery will
remain ongoing (Dunn, 2005).
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The nurse’s compliance with treatment should be monitored by human resources,
management, and, if available, an employee assistance program. While maintaining the
employee’s privacy, managers need to investigate any new charges against the nurse, and if a
relapse occurs, place the nurse on medical leave of absence until the state board or nursing
makes its ruling. If the nurse cannot abide by the return-to-work agreement, disciplinary action
must be taken per institutional policy (Dunn, 2005).
The best treatment option is early education and intervention. Nurses need to be educated
about addictions and what they should do if they find themselves in the situation. It is better to
treat nurses and retain them in the workforce (Dunn, 2005). The cost of rehabilitating the
impaired nurse may seem large, estimated from fifty thousand to almost one hundred thousand
dollars, but one study showed that reserving the nurse’s job while he or she was recovering cost
healthcare organizations less than replacing the nurse (Servodido, 2011).
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Postpartum Depression
Postpartum depression (PPD) is a serious mood disorder that affects women who have
recently given birth. It occurs in ten to fifteen percent of women and may develop at any time in
the first twelve months following a pregnancy. The general onset of PPD is within the first three
months following delivery. It is distinguished from the common postpartum blues experienced
by many women following a pregnancy by severity and length of duration (McKinney, James,
Murray, & Ashwill, 2009).
Pathology
The cause of PPD is unclear, but it has definite risk factors. Some of those risk factors
include: previous personal history of depression or other mental illness, depression during
pregnancy, primiparity, medical problems during pregnancy or following the birth, maternal low
self-esteem, difficult relationship with significant other, ambivalence about the pregnancy, single
motherhood, younger maternal age, inadequate social support, lack of sleep, financial concerns,
having an infant with health issues or a difficult temperament, multiple fetus pregnancy, and
chronic stress (McKinney et al., 2009, p. 709-711). Life stress, maternal self-esteem issues, lack
of social support, and marital conflict were identified as key risk factors by Miles (2011). These
factors are intensified when combined with a maternal history of depression or anxiety.
Symptoms of PPD include: suicidal thoughts, diminished appetite, crying, persistently
low mood, persistent fatigue, social withdrawal, insomnia, lack of drive, loss of interest in usual
activities, poor self-confidence, and feelings of uselessness, despair and helplessness (Miles,
2011, p.222). Other symptoms include caring for the infant but reporting an inability to feel
pleasure or love, weight changes, and difficulty making decisions. Symptoms are present for at
least two weeks, and tend to persist, gaining in intensity over time.
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Treatment Options
PPD treatment is generally a combination of medication, social support, and
psychotherapy. If necessary, electroconvulsive therapy may be indicated as well. Medications
used to treat PPD include: antidepressants, mood stabilizers, anti-anxiety agents, and
antipsychotics (Lowdermilk, Perry, Cashion & Alden, 2012). Medication may be prescribed for a
period of six months or more, but the woman’s breastfeeding status must be taken into effect
when prescribing drugs, as some are safer for lactating women than others. Women who have
discontinued medications for depression during pregnancy are more likely to have a relapse of
depression during the postpartum period Alternative treatment options to medications include
herbs, dietary supplements, massage, aromatherapy, light therapy and acupuncture.
Electroconvulsive therapy may be indicated in severe cases (McKinney et al., 2009).
Nursing Care
Nursing care of the woman with PPD includes assessing all pregnant women for
depression while they are still pregnant and following delivery. Nurses should take advantage of
follow-up calls to women and be sure to include questions about depression. Recognizing that
the mother may feel guilty about feeling depressed, the nurse can educate the woman and help to
remove some of the stigma associated with PPD. Screening mothers for signs of excessive
fatigue in the first two weeks postpartum, may also help to pinpoint women most at risk for
developing PPD. Assessment tools that may be administered include: the Postpartum Depression
Predictors Inventory, the Postpartum DepressionScreeening Scale, and the Edinburgh Postnatal
Depression Scale (McKinney et al., 2009).
The mother should also be assessed for feelings of sadness, depression, loss of interest in
normally pleasurable activities, and lack of family support. Subjective assessment for apathy,
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lack of energy or interest in baby, lack of interest in food, and severe sleeplessness should be
done. Crying, poor personal hygiene, and inability to follow directions are objective signs of
PPD. The nurse should also listen closely for verbalizations that indicate feelings of failure,
sadness, loneliness, or anxiety (McKinney et al., 2009).
Nursing interventions include demonstrating caring, providing anticipatory guidance,
helping the mother to verbalize her feelings, helping the mother to interpret infant cues, enlisting
family members (such as the father) to help with care, and discussing potential options and
resources with the mother. Giving the mother telephone numbers and meeting times for local
PPD support groups may be helpful (McKinney et al., 2009).
Following nursing interventions the mother should be better able to verbalize her feelings
with others and be able to identify resources, including her own personal strength, that will help
to support her through this difficult time. The mother should be able to discuss parenting in a
more realistic way and show more perspective when dealing with situations such as a fussy baby
or being home alone. Ensure that family members and the mother are aware of signs of
worsening PPD and that they know when they should call a healthcare provider. Develop a plan
with the mother to get more sleep, eat better, exercise, and avoid over committing herself
(Lowdermilk et al., 2012; McKinney et al., 2009).
Women identified as having severe PPD should be referred to a mental health practitioner for
further evaluation and therapy. Inpatient psychiatric hospitalization is sometimes indicated if the
safety of the mother or her children is threatened. If a nurse suspects delusional behavior, the
mother should be questioned about plans to hurt herself or the baby and referred immediately to
a psychiatrist experienced in working with women with PPD (Lowdermilk et al., 2012).
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References
California Board of Registered Nursing. Retrieved May 22, 2012 from
http://www.rn.ca.gov/diversion/whatisdiv.shtml.
California Board of Registered Nursing. (2011) Uniform standards related to substance abuse
and disciplinary guidelines. Retrieved May 22, 2012 from
www.rn.ca.gov/pdfs/regulations/proplang39112.pdf
DeClerk, P. (2008). Recognizing the chemically impaired nurse. ASBN Update, 12(4), 12-13.
Dunn, D. (2005). Substance abuse among nurses - defining the issue. AORN Journal, 82(4), 573596.
Dunn, D. (2005). Substance abuse among nurses - intercession and intervention. AORN Journal,
82(5), 777-799.
ISNAP Indiana State Nurses Assistance Program. Retrieved May 22, 2012 from
http://indiananurses.org/isnapsite/warning_signs.php.
Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2012). Maternity & women's health care.
(10th ed.). St. Louis: Mosby, Inc.
McKinney, E. S., James, S. R., Murray, S. S., & Ashwill, J. W. (2009). Maternal-child nursing.
(3rd ed.). St. Louis, MO: Saunders.
Miles, S. (2011). Winning the battle: A review of postnatal depression. British Journal Of
Midwifery, 19(4), 221-227.
Servodidio, C. A. (2011). Alcohol Abuse in the Workplace and Patient Safety. Clinical Journal
Of Oncology Nursing, 15(2), 143-145.