How to Help Nurses With Substance Use Problems Get Help

As part of an investigation into substance use among nurses amid the pandemic, MedPage Today asked experts and peer support advocates how to identify a nurse who might be struggling with alcohol or drugs and how best to help connect them to care.

Deborah Koivula, RN, BSN, CARN, the Eastern Regional Coordinator for the Statewide Peer Assistance for Nurses (SPAN) program in New York, said there are a number of signs to look for that can indicate a substance use disorder, although those signs can differ based upon the work environment and the type of substance involved.

Signs of Substance Use

Physical signs of substance use can include bloodshot eyes, shaking hands, or changes in a nurse’s alertness — such as appearing sleepy or tired, Koivula said.

Other changes to look for that can signal a problem include the “track marks” of scarring and discoloration along a vein used for injecting drugs, significant weight loss or gain, and deterioration in a person’s appearance, according to an online flyer from the American Association of Nurse Anesthesiology (AANA).

Nurses might try to mask some of these physical warnings signs by treating their own withdrawal symptoms, said Koivula, but it usually catches up with them eventually. “As people progress through the disease process, they may think that they’re presenting better than they actually are… [but] that cognitive decline becomes harder to manage.”

Koivula also noted that it’s very often some of the hardest working, most respected nurses who succumb to addiction.

“They internalize that perfectionistic expectation … when sometimes it gets to be too much,” Koivula said. It isn’t uncommon for colleagues to look back and say, “I never saw this coming.”

The AANA notes several other behaviors to look for including severe mood swings, personality changes, poorly explained errors, and difficulty concentrating or recalling details and instructions. Colleagues may also notice that a nurse takes longer than usual to complete ordinary tasks.

But the warning signs and behaviors can also vary by the type of drug. A person in alcohol withdrawal may show up late to work or not show up at all; whereas someone diverting medications from the workplace may show up to work more often, even when they aren’t scheduled, Koivula noted.

There are also the “more extreme cases” where colleagues notice patients complaining of pain, find inaccurate medication counts for controlled substances, or smell alcohol on a nurse. Those are the kinds of red flags that require immediate intervention, she said.

Compassionate Intervention

The goal of connecting a nurse to support for a potential substance use disorder should always be a “compassionate intervention,” Koivula said.

Nurses who have to step away from their caregiver role and into a “care-receiving role” may find it an incredibly difficult transition to make, she noted.

“So if someone needs to be removed from practice, we want to do it in a way that keeps the public safe but also respects the fact that this nurse is now a patient and deserves the same level of respect and regard that we would extend to any of the patients that we’re caring for,” Koivula said.

Some 93% of nurses surveyed said they would tell a supervisor if they believed a colleague had a substance use disorder, according to a study in the Journal of Nursing Regulation. However, only about half said they felt confident they could identify a nurse with a substance use problem based on their appearance or behavior, and 58.5% expressed concerns that a colleague with a substance use disorder might be fired or punished.

It’s important to make nurses aware, in a matter-of-fact way, that substance misuse is something that happens to nurses and that they are at greater risk for it but also that there are things that can be done to help, said first author of that study, Alison Trinkoff, RN, ScD, of the University of Maryland School of Nursing in Baltimore. “Everybody kind of benefits from getting it dealt with.”

As Koivula noted, nurses often come into treatment late in their disease progression. Greater education both around the signs and behaviors signaling a potential problem and around hospital policies for addressing a nurse who has a substance use disorder could encourage more reporting, Trinkoff argued.

Studies have demonstrated that when someone does something “courageous” like speaking up and the outcome is not punitive but instead “fair and helpful,” they are more inclined to do so again.

Trinkoff compared concerns around substance misuse to concerns around medical errors and patient safety in the way, she believes, they should be approached.

Instead of “‘Who did this? Let’s fire them,'” Trinkoff suggested, “It’s like, wait a minute, ‘How did this happen? Where did the system break down?'”

When things are out in the open, care can be improved; but when a problem is a “big secret,” is treated punitively, and there’s stigma, “nothing happens,” she said.

Alternative-to-discipline programs, a less punitive process available in more than 40 states when no patient harm has been found for first-time offenders, can help nurses avoid losing their license, Koivula noted. It’s important that colleagues and managers help nurses to engage those services, she added.

The ‘Worst’ Response

One thing Koivula and her colleagues always encourage is that hospitals and health systems avoid immediate termination whenever possible.

“We’ve heard horror stories where nurses were just pulled into an office, terminated, and just sent on their way with no support at home, no one to talk to in a situation where they’re just emotionally flooded,” she said. In some situations, there have been nurses who attempted and completed suicide.

Another Journal of Nursing Regulation study, published in April, found that job loss — particularly when due to substance use, chronic pain, or a mental health problem — places nurses at increased risk for suicide.

“The worst thing” that an agency or facility can do is to intervene in a way that isolates the nurse, Koivula said.

She and her colleagues encourage hospital and health facilities to have compassionate protocols and policies in advance of having to address these situations and to work with their human resources and internal teams to determine whether a medical leave of absence might be the more appropriate route. Nurses are also more likely to engage in treatment if they have insurance and financial support, she stressed.

In some cases, peer advocates are able to meet with nurses as the interventions are taking place to let them know that while they may feel alone or scared, other nurses have been through the same experience.

“It’s an opportunity for us to link them with a peer who’s been in that situation and actually survived it and is maybe in long-term recovery,” Koivula said. “Maybe they had some impact on their license, but they’re thriving and they’re doing well down the road.”

“The other, worst thing that you can do, which is unfortunately common … is to ignore it,” Koivula said.

If a colleague notices warning signs, “it’s a ‘see something, say something’ moment,” Koivula said. “It’s better to intervene and assess the situation to see if the red flags are substance-related.”

It’s possible that a colleague has mistaken a mental health issue, burnout from COVID, or even a physical health issue — such as shakiness from hypoglycemia in diabetes — for a substance use problem, she said.

“But if it is [substance use-related], the spiral downward is so quick for nurses that it’s better to say something and be wrong,” she said.

Koivula and others in the recovery field are trying to create a culture where intervening is encouraged and no longer seen as punitive, where “we’re kind of all one, all looking out for each other,” Koivula said.

Her program, SPAN, is confidential and voluntary, not an arm of the discipline process, she said.

Its peer support groups are particularly helpful, she noted, in cases where legal action has been taken or a nurse’s license has been suspended or revoked, as a space to process the shame, grief, and loss of identity that can follow.

Changing the culture around substance abuse to one that’s less punitive, and educating people to understand how to respond to, report, and screen for substance use is important, Trinkoff said.

If there’s a silver lining to the pandemic, it’s been that it forced issues like the health and well-being of nurses to become a priority, Trinkoff said.

“Because if we don’t have them, we don’t have health care.”