Abstract
When nurses have active and untreated addictions, patient safety may be compromised and nurse-health endangered. Genuine responses are required to fulfil nurses' moral obligations to their patients as well as to their nurse-colleagues. Guided by core elements of relational ethics, the influences of nursing organizational responses along with the practice environment in shaping the situation are contemplated. This approach identifies the importance of consistency with nursing values, acknowledges nurses interdependence, and addresses the role of nursing organization as moral agent. By examining the relational space, the tension between what appears to be opposing moral responsibilities may be healed. Ongoing discourse to identify authentic actions for the professional practice issue of nursing under the influence is called upon.
Keywords
Human flourishing is enhanced by healthy and ethical relationships, and morality is rooted in the collective life. (Solomon Benatar) (p.xii)
1
It is worthy of note that, in North America, two popular television shows featuring health care professionals (Nurse Jackie and House) portray central characters as having an addiction. Vicodin is the drug of choice for House, a fictional medical genius, who claims in one episode that these ‘help me to do my job’. 2 Nurse Jackie self-medicates, for chronic back pain related to an occupational injury, with analgesics stolen from the hospital pharmacy. In objection to the unethical behaviour of Nurse Jackie, the New York State Nurses Association recommended Showtime include a disclaimer reminding viewers that Jackie is not representative of the profession (Showtime has not). 3
While it is problematic that such characters may be shaping the public’s image of health care providers, it is perhaps more troubling that ‘nursing under the influence’ is being more openly addressed on television than within the nursing profession. In this article it is argued that nurses have a fundamental responsibility to each other as well as to those in our care and that we need to find authentic, ethical ways of responding to nursing-colleagues whose lives, practices, and patients are placed at risk as a result of addiction. A relational ethics approach is put forward as a guide to revealing such responses.
The situation of addiction in nursing
Nursing provides rewarding and enriching careers for its members but, at the same time, often proves to be demanding, stressful, and isolating. Nursing practice is disheartened with decreasing autonomy and job satisfaction, 4 increasing workforce shortages with the consequential burden of overtime, 5 unacceptable rates of assault and injury, 4 and emotionally draining experiences that include moral distress, 6 compassion fatigue, 7 and anger. 8 In an attempt to cope, some nurses engage in dysfunctional consumption of alcohol and other drugs and, if predisposed, are placed at greater risk for developing an addiction. 9
Through historical research, Heise 10 uncovered a 1907 article by Annie Hobbs referring to six nurse-colleagues who, having used alcohol to help them sleep when exhausted from their demanding work, were dismissed. Each left with a ‘slur on her character.’ Addiction remains relevant to 21st century nursing practice with evidence suggesting the prevalence among nurses may be similar to the general population. 11 If correct, over the next 12 months approximately 8.5% of nurses will have an alcohol addiction 12 and a further 2% will be addicted to drugs. 13 When nurses with active, untreated addictions provide care, impaired practice may compromise patient safety. 14 If drugs are accessed from the workplace, and results in under-medication of patients, patient suffering may occur. At the same time, nurse health is threatened as the disease of addiction is typically marked by suffering, progresses in severity, and may result in premature death. 15
The scope and critical nature of this professional practice issue demands nursing determine how best to deal with it. Nursing does not have a strong reputation, on the whole, for treating its members well: the question has been raised whether nurses ‘eat their young,’ 16 horizontal aggression has been researched, 17 and vertical violence described. 8 In the past, nurses with addiction have been disciplined, lost their licenses, terminated involuntarily (the ‘throwaway nurse syndrome’), denied employment, and even incarcerated.10,18,19 This history has led some critics to remark that ‘nursing is an army that shoots its wounded’ (p.154). 19
Such statements should serve as a ‘wake-up call’ for the profession. Nurses need to examine our relationships with one another, to use our knowledge and expertise to openly address ways of responding to a serious health issue facing some nurse-colleagues. Relationships and commitments among nurses matter deeply as nursing, by its very nature, is practiced among a community of nurse-peers. This interdependence contributes to the context and environment in which we work and shapes our very nursing practice. 20 In this sense, the situations of our nurse-colleagues cannot be isolated from our own circumstances. As it is through meaningful discourse that genuine understanding occurs and authentic responses are identified, 1 nurses and nursing organizations are called upon to become engaged with exploring how to best deal with the situation of addiction within nursing.
Relational ethics: recognizing the human connection
Nursing practice is grounded in ethics,21–24 and ethical responsibilities apply in all nurse interactions with individuals, families, student, health-care professionals – as well as with our nursing colleagues. 22 Nurses are compelled to address threats to the delivery of safe, competent and ethical nursing care, as may be the case when nurses are impaired by the use of substances. Moral obligations are also raised when nurses develop addiction, particularly as the high stress of caring work and concomitant access to substances may have placed them at risk. 9 Nurses have responsibilities to work with others to create moral communities of practice and the quality of the work environment in which nurses' practice is crucial to their ability to practice ethically. 22 An ethic that considers interpersonal commitments while recognizing environmental influences can guide our attentiveness and responsiveness in this complex situation.
It has been argued that traditional approaches to bioethics, those that focus primarily on moral reasoning derived from philosophy, are insufficient for exploring moral experiences and interaction in healthcare environments.1,20 Recognizing the human connection to be as crucial to ethics as moral reasoning, the Relational Ethics Project at the University of Alberta in Edmonton, Canada, endeavored to elucidate ethical commitments required in health care situations. 1 An interdisciplinary research team applied qualitative research methodologies for the purpose of developing a comprehensive and philosophically-grounded relational ethic through exploration of the critical question: how should we be with one another? 1 Based on the assumption that ethical practice is situated in relationships, core elements essential to ethical relationships were revealed and these include trust, mutual respect, embodied knowledge, and recognition of the interdependent environment. 23 In the relational ethics framework the use of ethical priniciples, including ideas of virtue, duty, rights, and consequences, are still encompassed but the emphasis is placed on the way in which such understandings are enacted.23,1
As relational ethics allows for new ways of thinking, inquiring, and addressing the challenges presented in everyday healthcare activities, and as examining issues of power and vulnerability in health care situations are viewed as crucial within this ethic, relational ethics is particularly well suited for considering responses to nurses and addiction. Core elements of relational ethics, specifically trust, mutual respect, embodied knowledge and recognition of the interdependent environment, will be described and explored to determine the shape and form of ethical responses between nursing (nurses and nursing organizations) and nurses with addiction.
The need for genuine trust
Trust is an essential element of being that affects the way we experience the world; it affects the way we engage with one another and every relationship we have involves its presence or absence (p.317). 24 The need for the public to trust the care of health professionals is obvious and reputation alone can serve as a basis for initial trust. 24 Although the general public places nursing at the top in Gallop’s annual ‘Honesty and Ethics of Professions' poll, 25 reputations are not static and nursing must continue to earn this high regard. When only a few nurses are determined untrustworthy, the general perceptions of the trustworthiness of nurses and the profession at large is harmed. 26
Such a threat occurs when nurses practice with active and untreated addictions. Impairment related to substance abuse can have detrimental effects on nurses' performance through negative impacts on alertness, attention, concentration, reaction time, coordination, memory, multi-tasking, perception, and thought processing as well as on self-estimation of impairment and disinhibition. 15 These performance measures partially explain why impairment due to an active and untreated addiction is generally considered incompatible with employment in safety-sensitive positions, including nursing. 14
The privilege of self-regulation is grounded in the ability of the public to trust the nursing profession has the capability to ensure their members provide safe, competent, compassionate, and ethical nursing care. To fulfill this fiduciary responsibility, organizations which license nurses (e.g. colleges and associations or state boards of nursing) are provided authority to enforce standards and ethical codes. These provisions may include directing for mental and/or physical examination, directing for submission to treatment, undertakings, conditions for practice, reprimands, suspending or revoking licensure, fines, and public disclosure. 27
This authority has been invoked when nurses are reported for behaviours related to their use of substances; almost one-quarter (24%) of discipline and license violations in a review of data from the National Council of State Boards of Nursing in the USA were related to substance use. 27 Disciplinary responses penalize nurses who are impaired and prevents their practice for the purpose of protecting the public, 28 and are consistent with the historical reliance on the deterrence model of punishment to control the use of addictive substances. The underlying belief to the deterrence model is that the threat of punishment will deter undesirable actions, which assumes that individuals are rational, their actions are logical, and the cause of the problem is intentional. 29 There is a profound disconnection between this assumption and what is now known about the disease of addiction. Research has identified addiction as a brain disorder characterized by compulsive drug seeking and use. Although the condition initially comes about because of voluntary behaviour, prolonged use may induce a chronic, relapsing disease – a health problem requiring treatment rather than punishment. 29
Nurses in recovery from addiction, in a phenomenological inquiry, identified risk of disclosure, disciplinary action and loss of licensure as barriers to seeking treatment. 31 Experts in addiction medicine concur, noting exposure and punishment of individuals with addiction-related disorders effectively denies their access to early treatment. 32 Policies aimed at early and confidential identification of addiction, with provisions for appropriate treatment and return to career-track without prejudice, have been recommended by the American Nurses Association, the International Nurses Society on Addiction, and the National Council of State Boards of Nursing. 28 Within a rehabilitative paradigm, confidential agreements provide for return to practice following successful treatment and may be conditional on commitment in long-term aftercare (e.g. five years) programs. Aftercare programs monitor for early detection of relapse through random drug screening, continued engagement in ongoing, multi-modal treatment, and occupational accommodation. 33
The policy approach (disciplinary or rehabilitative) for nurses with addiction can affect the actions of other nurses impacted by their situation. Nurses are morally obliged, if not required as a standard of practice, to protect the safety of patients receiving nursing care.21–24 When patients are perceived to be placed at risk, nurses are expected to take steps to ensure safety and, when appropriate and feasible, approach the nurse-colleague in question as well as seek confidential advice from relevant authorities on reporting. Although difficult, addressing the situation of a nurse-colleague with an addiction can be the turning point in their illness; some recovered nurses believe it was such action by their nurse-colleagues that saved their very lives. 31 It has been estimated that only 37% of nurses who knowingly work with a nurse-colleague suspected to be impaired will report, 34 and those nurses who believed that punitive, as opposed to rehabilitative, consequences would result were less likely to report. 35 As nurses are the primary source of detection of nurses with addictions, 36 barriers to their ability to act are particularly relevant for ensuring the provision of safe nursing care.
The landscape of policies within nursing is not consistent as some jurisdictions have adopted rehabilitative programs while others continue with disciplinary approaches. In some programs, discipline occurs concurrently with treatment and recovery conditions. 27 A nursing review comparing the two approaches concluded that rehabilitative policies were more compassionate and attentive to nurse health. 28 Although similar research does not yet appear to be available for nurse outcomes, prospective and retrospective studies on physicians managed with confidential, rehabilitative approaches that include long-term (5 year) monitoring programs report 79 to 85% licensed and practicing upon their completion.37,38
It is imperative that the nursing profession implement policies that ensure the delivery of safe and ethical nursing care and meaningfully address critical violations of practice standards. Disciplinary policies may provide the appearance that the profession is dealing seriously with its members for behaviors related to their addiction. However, the rationale for intervention when nurses practice with active and untreated addiction is to protect patients and not to punish nurses. 39 As discipline has not been found an effective measure for prohibiting addiction but has been found to be a barrier against treatment seeking, and the reporting of unsafe practice, its use increases the risk to public safety as well as to nurses' health in this situation. For these reasons, disciplinary policies cannot be held as a genuine measure to fulfill our obligations for providing safe nursing care. Their ongoing use could be perceived as a betrayal of the trust the public has placed in the nursing profession.
Mutual respect: mitigating powers' potential to damage
Mutual and respectful openness to all points of view enhances our understanding of one another but requires authenticity, not merely appearance. Treating individuals with respect is arguably foundational to everyday nursing practice, and specifically addressed in many ethical codes.19–22 Mutual respect mitigates power differentials thereby reducing the vulnerability experienced by those who are marginalized or stigmatized due to factors such as poverty, gender orientation or disease. 23
Mutual respect is of extreme relevance within the context of addiction given the powerful stigma associated with the disease. Stigma discredits, devalues and distances, and continues to be a barrier for individuals with addiction. In a US survey, half of the public identified that addiction was a ‘personal weakness,’ and that ‘lack of willpower’ was the main problem facing people with addictions. 40 Only half of Canadians identify drug addiction (51%) and alcoholism (49%) as serious illnesses or mental illnesses, and just one-fifth (21%) would socialize with a co-worker who has either an alcohol or drug addiction. 41 In a qualitative study on stigma experienced by individuals with HIV, one participant shared that ‘there is more stigma… in my life right now with regard to being a drug addict than there is with my HIV and hep C status' (p.175). 42 For those experiencing stigma, the outcomes are often problematic and humiliating. These may include social rejection, loss of or inability to obtain employment, alienation from family and friends, political marginalization, and other forms of subtle and overt discrimination. 43
Unfortunately, expressions of stigma and discrimination towards individuals with addiction are not confined to the general public; they can come from health professionals despite the specialized knowledge gained from their education and experience. Nurses in recovery from addiction have acknowledged delayed treatment seeking because of the stigma they felt from within their workplace, and that this procrastination prolonged their illness. 31 In a phenomenological inquiry into recovered nurses' experiences, one informant poignantly asked, ‘I’ve been clean and sober for 13 years. How much longer do you suppose I will be [considered] impaired?’ (p.176). 18
If reducing stigma is fundamental to improving the situation for nurses with addiction, a critical question becomes: how is stigma expressed within nursing? When actions are founded on stigmatizing attitudes, they are discriminatory in nature if depriving the stigmatized person of rights and entitlements. 43 Confidentiality is a condition of respect and human dignity provided to individuals regarding matters of their health. It provides a level of protection from stigma, and is considered an essential precondition to successful treatment for individuals with addiction. 44 In contrast to nurses with other disease conditions, confidentiality is not always afforded to nurses with addiction. Public hearing tribunals and publication of discipline decisions occurs in some jurisdictions (example provided in Figure 1 ) to ‘provide for public safety’ (p.26). 45
A discipline decision.
When a nurse with an addiction is restricted from practice until considered safe to return to practice by their treatment providers and nursing licensing bodies and monitored for the early detection of relapse, then there is no need for members of the public to avoid care by that particular nurse. Public disclosure is a humiliating and stigmatizing experience that increases the vulnerability of a nurse with a serious illness, and is a demonstration of powers' potential to damage. Providing confidentiality to nurses with addiction is a fundamental condition of mutual respect, a critical measure of reducing stigma, and a necessary condition for nurses to recognize and seek treatment for their serious illness.
Embodiment: healing the split between mind and body
Emotional life is as important to human life as physical signs and symptoms, and shapes the landscape of our mental and social lives. Emotions are value judgments that have great importance for flourishing but are outside of our control. 46 Nurses' emotions are a part of the response of their body, a part of their experience, and can inform their cognition and reasoning. 58 Balancing subjective feeling abilities and objective thinking skills is another key element, termed embodiment, in relational ethics. 1 Individual nurses are, of course, unique in their embodied understanding toward the situation of addiction in nursing but common to nurses is our fundamental commitment to health and high regard for the provision of safe, competent, compassionate, and ethical nursing care,21–24 For the purposes of contemplating embodiment for the situation of addiction within nursing, these core values will be considered representative of the profession.
Nurses view practice impaired by addiction as a very serious offense. 34 Behaviors which have been exhibited by nurses with addiction – such as withholding or under-dosing patients, theft of medications from an employer, attending on duty when impaired by drugs or alcohol, falsifying hospital records, writing illegal prescriptions, wastage errors, and sales of drugs 27 – go against the essence and the particulars of nursing practice standards and codes of ethics. Headlines such as ‘Rogue nurses leave quietly: They stole narcotics, made medical mistakes and abused patients,’ 47 shame the profession. It is difficult to be compassionate with nurse-colleagues who engage in actions that endanger patient safety, place themselves or other health team members at risk, and damage our professional image.
Given these contraventions to professional conduct, why would a nurse with an active and untreated addiction continue to practice? Nurses have a professional responsibility to withdraw when they do not have the capacity to practice safely and competently. But denial is one of the defining features of addiction, and individuals in denial may be unaware of the true nature and extent of his or her addction. 15 As one recovered health provider aptly explained, ‘This is a disease that tells you that you don’t have it. It’s the only disease I know that argues with you and says, “Look, despite all the evidence, you don’t have a problem”’ (p.3). 48 Some recovered nurses describe how their need to access substances and hide their use had organized their very workday. 31 While making her daughters' school lunches, Nurse Jackie inserts crushed Percocet into artificial sweetener packages for ‘mid-morning, mid-afternoon and the long ride home. Should be a good day’. 49
Nursing is a compassionate discipline, often referred to as the front line of health care, tasked with interpreting realities with the purpose of enhancing the human health condition. Nursing organizations, exemplars of the profession to the public and to their membership, provide tangible evidence of the norms, values, and standards of nursing through their actions. 50 As actions declare values, the responses of nursing organizations to their members with addiction declare their values to addiction. When there is congruency between their response and the values embraced by the profession (e.g. as delineated in codes of ethics and standards of practice), then nursing is enhanced. 51 In this manner, when nursing organizations embody our professional values in their relationships with nurses with addiction, they function as moral agents and model approaches that can improve outcomes for patients in similar situations. This raises the question: When the actions of nursing organizations more closely reflect the criminal justice system rather than the compassionate purpose of healthcare, does this diminish the moral climate of nursing as a profession? It is through the very treatment of our nurse-colleagues with addiction that the principle of acting locally to influence globally may be achieved.
Attention to the interdependent environment
Addiction is a complex disease with a multi-factorial pathogenesis. Individuals may develop the disease regardless of their age, gender, sexual orientation, socio-economic status, education, culture, religion, or occupation. 30 A multitude of health determinants have been identified in the onset and progress of physical or psychological addiction, and one of these is the broader environment. Although nurses have individual vulnerabilities and characteristics that may place them at risk for developing addiction, nurses share the context and environment in which they practice.
Studies examining the relationship between nurses' practice environment and addiction suggest that the high job strain that comes with nursing, 52 the disruption and fatigue related to shift work, 31 the ease of access to medications and the knowledge of their effects,9,31 as well as practice in certain specialities 52 can be factors associated with addiction. The theme of the premier episode of Nurse Jackie addressed this relationship. Prior to self-medicating in preparation for work, Jackie muses, ‘What do you call a nurse with a back injury? Unemployed.’ 54
Unfortunately, it is not unusual in health care for the focus of accountability to be placed exclusively on the practitioner, without due regard for the responsibilities and obligations of the institutions within which they practice and their professional organizations. This paradigmatic approach has been challenged by findings that errors made by health professionals reflect systemic and organizational issues. 55 Solving the problem is recognized as a matter of examining the environment in which individuals and teams practice.
Nurses have, or have the potential for, incredible influence on the culture and climate in which they practice. In addressing the situation of nurses with addiction, the broader conditions affecting the health and wellbeing of all need to be addressed. The nursing profession has been working to define and advocate for healthy work-life environments for nurses. It is acknowledged that attention to promoting health, safety, and wellness for nurses is critical and, ultimately, promotes the best outcomes for our patients. It is time the profession acknowledges the systemic influences on nurses' development of addictive disorders and demand that such influences be studied and addressed. The at-risk nurse should not feel – and be – terribly alone.
The promise of a relational ethic
Nursing practice impaired by an active, untreated addiction is a critical professional practice issue that requires genuine action from the profession. A relational ethics approach guides contemplation to uncovering such authenticity; it asks us to consider whether responses genuinely ensure patient safety and whether nurses with addiction are treated as we would want to be if in their situation. By examining the connections between people – the relational space – the tension between what appears to be opposing moral responsibilities may be healed and new understanding generated. 1
Consideration of certain core elements of relational ethics shifts the focus from the isolated, individual nurse to include broader contextual issues that includes the influences of nursing organizational responses and the practice environment in shaping their situations. As nurses are mutually dependent on one another, sharing the context and environment in which we practice, reframing this professional practice issue from the problem of an individual nurse to ‘nursing under the influence’ better reflects our interdependence and the influence of the environment.
Our values and beliefs as nurses are expressed in the manner in which we treat one another; the actions expressed through nursing organizational policies declare what really counts to the profession. 49 Our responses as a profession to the issue of addiction in nursing must be congruent with the ethical understandings that we espouse in response to those in our care. When we do not use our nursing expertise or enact our discipline’s fundamental values and respond ethically to nurse-colleagues who are suffering with an addiction, we fail them as well as ourselves.
If ethics is about how we should live, then relational ethics is essentially about how we should live together. 23 Relational ethics can be a guide for identifying fitting responses to this serious professional practice problem. It can be used to frame a meaningful dialogue among us, one that has the potential to generate new knowledge and understanding. It can help us sustain ethical relationships with one another.
Footnotes
Acknowledgements
Diane Kunyk has received scholarships for her doctoral program from: Social Science and Health Research Council; Canadian Institute of Health Research; University of Alberta; Alberta Registered Nurses Educational Trust; United Nurses of Alberta; and, Canadian Nurses Foundation. She has also received the Presidents Doctoral Award of Distinction at the University of Alberta, the Sandy McKinnon Memorial Graduate Scholarship in Nursing, and the Meredith Graduate Fellowship.
Wendy Austin has received research funding from: Social Science and Health Research Council; Canadian Institute of Health Research; and the Alberta Heritage Foundation for Medical Research.
Parts of this article were previously presented at the Canadian Nurses Association Biennial Convention entitled ‘Innovation in Action: The Power of Nursing’. Halifax, Nova Scotia, 8 June 2010.
The authors wish to declare that there is no conflict of interest.