What action is best for the community health nurse to take if the nurse suspects?

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Q. I am a frontline RPN and I recently witnessed a nursing colleague provide care to a client that I perceive to be unprofessional. The nurse’s actions compromised the client’s safety and well-being. When I reviewed the College’s mandatory reporting document, I noticed it only states that nurses are required to report sexual abuse of a client. Although this situation does not involve sexual abuse, I feel as though this is something I need to report but I am concerned about client confidentiality and my professional relationships. What are my accountabilities?

A: When a client’s safety and well-being are compromised, your primary responsibility is to the client. As a nurse, you are accountable for reporting to the appropriate authority, any team member or colleague whose actions or behaviours toward clients are abusive in any manner. Abuse may be physical, verbal, emotional, financial, sexual, or take the form of neglect.  Any type of client abuse is considered professional misconduct.

Depending on the nature of the abuse, examples of an appropriate authority you can report to include the College of Nurses of Ontario, another health regulatory body or your employer.

Also remember that you are accountable for ensuring that your practice and conduct are in alignment with the standards of the profession and other legislation that applies to your specific practice setting.

At times, nurses will learn information which, if not revealed or reported, will result in serious harm to the client. Some legislation requires that nurses reveal confidential information to others. This duty supersedes other accountabilities regarding client confidentiality.

Below are examples of College documents, and legislation related to specific practice settings, that all nurses must keep in mind when considering their reporting requirements.

Some expectations of the profession

The College’s Professional Standardsstate that nurses take action in situations where a colleague’s actions or behaviours put clients at risk or are perceived to be abusive toward a client in any way.

The Therapeutic Nurse-Client Relationship practice standard, says that nurses have a commitment to clients to act in their best interest by providing safe, effective and ethical care, and their actions must promote trust and respect of the profession – this would include reporting any form of abuse to an appropriate authority as explained above.

Some applicable legislation

An example of specific legislation that informs nurses’ reporting requirements is the Fixing Long-Term Care Act, 2021, which outlines the obligation for nurses to report improper or incompetent care of a client, or abuse that results in harm or a risk of harm.  

If the client abuse involves a child or youth, the Child, Youth and Family Services Act, 2017 requires all health care professionals to report the suspected abuse.

For more information, please see the following resources:

Ethics
Preventing Client Abuse
Professional Misconduct
Confidentiality and Privacy: Personal Health Information

Page last reviewed July 14, 2022

Substance abuse occurs across all generations, cultures, and occupations, including nursing. About 1 in 10, or 10-15% of all nurses, may be impaired or in recovery from alcohol or drug addiction. Although nurses aren’t at a higher increase risk than the public sector, their overall pattern of dependency is unique because they have greater access to drugs in the work environment.

Impaired nurses can become dysfunctional in their ability to provide safe, appropriate patient care. Addiction is considered a disease, but the addicted nurse remains responsible for actions when working. Nurses should be aware of the signs and symptoms of substance abuse and know when to report a coworker suspected of substance abuse to management.

Consider the following questions and situations.

What does a substance abuse nurse look like?

“Have you seen Jane lately? She used to be so neat and clean but for the past several months she doesn’t seem to care about her appearance,” stated Polly. “I worked with Jane this week and she seemed in a daze most of the shift,” replied Tom. “If I didn’t know better I would think Jane was taking drugs or something,” Polly commented. “Drugs! Not Jane, she would never take drugs. I’ve known Jane for four years. She’s an excellent nurse,” Tom replied, “Besides Jane certainly doesn’t look like a drug user. She’s probably just tired from working the night shift or maybe she’s having some personal problems. We all deal with our problems differently.”

Would you be willing to inform management if you suspect a nurse is diverting medication?

“Sally do you have a minute? I need to talk to you about something I witnessed last week,” asked Dave. “Of course, what is it?” replied Sally. “I was working extra last week and about 9 pm. I answered a patient’s call light for Joe. The patient told me she was not getting any relief from her pain medication that Joe had administered over an hour ago. When I found Joe he was coming out of the bathroom with a syringe in his hand. I asked Joe what he was doing with the syringe in the bathroom. Joe seemed nervous telling me he was getting ready to give some Demerol to the same patient who was complaining of unrelieved pain. When I told Joe I had just talked to the patient and she supposedly had already had the pain medication, he became upset and asked me why I was questioning him. He did not talk to me the rest of the night. I don’t know if it means anything, and I don’t want to cause a problem for Joe, but I just have a feeling that something is not right,” Dave said.

Have you or a co-worker ever come to work after consuming alcohol?

“Wow you seem unusually wired tonight,” Carol said. “I know. Mark and I were at a party. I almost didn’t make it on time,” explained Megan. Who’s party was it?” asked Carol. “Oh an old friend of ours was in town so about 12 of us met at Randy’s,” Megan continued. “Isn’t that a bar?” asked Carol. “Yes, I probably had one too many drinks, but I’m fine. I can hold my liquor as well as anybody. I’ll just drink more coffee tonight!” Megan said proudly.

Reflect on your answers to the above questions. Could you recognize a nurse who might be engaged in substance abuse? Would you be able to identify medication diversion? Would you recognize impairment from alcohol in a co-worker? To be able to answer these questions, you need to understand the myths and truths about substance abuse.

Common myths and truths

Myth: Impaired nurses use only street drugs.
Truth: Many substance-abusing nurses use everyday medications encountered in the workplace as well as common street drugs. The problem may begin by simply taking a patient’s medication for a headache or back pain or to cope during a stressful shift. A substance-abusing nurse may substitute saline for injectable medications such as Demerol, morphine sulfate, and codeine, or dilute liquid medications after consuming some of it. Legal drugs are as harmful as illegal drugs.

Myth: Impaired nurse have a long history of drug or alcohol abuse.
Truth: Although many substance-abusing nurses have a history of long-term drug or alcohol abuse, a recent stressful life event such as a divorce, accident, or illness can lead to drug abuse as a coping mechanism.

Myth: Impaired nurses are easy to recognize.
Truth: There are specific signs and symptoms of a substance-abusing nurse, but the nurse may take extra precautions to avoid detection.

Myth: Drug addiction is voluntary.
Truth: Drug addiction is a compulsive behavior affecting the brain. It may be the result of an emotional or abusive family situation, poor choices, loss of support systems, excuse for behaviors, seeking an adrenaline rush, family history of addiction, enabling behavior, unstable lifestyle, denial, or other factors.

Myth: Combining drugs is not harmful.
Truth: Combining drugs can lead to disastrous consequences such as permanent physical impairment or death.

Myth: Addicts cannot recover and only need treatment for a couple of weeks.
Truth: Short-term in-patient programs should be at least 21 days. It is important to have follow-up supervision for physical and emotional support. The length of treatment and the willingness of the nurse are the best predictors for success. Nurses who remain in treatment for at least a year are twice as likely to be drug free, but the struggle for recovery will last a lifetime. Impaired nurses can make a complete recovery if given support and opportunity and they have a desire to recover.

Myth: Addicts have to want treatment and can’t be forced into it.
Truth: In most cases the substance-abusing nurse resists entering a treatment program. The main reasons for entering treatment are a court order and peer, management, and family member encouragement.

Myth: Alcoholics can sober up quickly.
Truth: It takes about three hours, depending on the person’s weight, to sober up. Reporting to work after attending a party and consuming alcohol is a recipe for disaster.

Myth: Beer doesn’t have as much alcohol as hard liquor.
Truth: A 12-ounce bottle of beer has the same amount of alcohol as a shot of 80% proof liquor or 5 ounces of wine.

Signs and symptoms of a substance-abusing nurse

As nurses we care for our patients, but we don’t always care for our coworkers or ourselves. As you read the Weighted Checklist you may discover you are working with or have worked with a nurse who displays signs, symptoms, and behavioral changes that may indicate substance abuse.

The most common substances abused by healthcare professionals are alcohol, cocaine/crack, Ritalin, marijuana, inhalants, ultram, methamphetamines, ecstasy, hallucinogens and stadol, sleeping pills, antidepressants, morphine, Demerol, percodan, vicodin and codeine. However, coworkers should never underestimate the need or desire for drugs from a substance-abusing nurse. The nurse might use whatever drug is available to satisfy the addiction while at work.

As a peer you should be aware that an impaired nurse who abuses alcohol would probably drink before reporting to work, during breaks and meals. Soft drinks, coffee, mouthwash, mints, and gum can be used to mask the alcohol odor. When signs and symptoms are obvious to others the substance-abusing nurse may be in the later stages of the disease.

What to do if you suspect a nurse is a substance abuser

Nurses must educate themselves on the signs, symptoms, behaviors, myths, and truths that represent substance abuse. While it may be very difficult to suspect a co-worker of substance abuse, and the fear of reprisal may keep some nurses from action, it’s important to take the steps necessary to confront or notify the nurse manager of your suspicions.

Educate yourself on the organization’s policy and procedures for employee substance abuse and employee assistance programs. Careful documentation of any changes in the suspected impaired nurses’ behaviors is important. If you are willing, you may choose to urge the nurse to seek help. Avoid any desire to enable the impairment.

Legal aspects to report a substance-abusing nurse vary among individual states, but nurses have an ethical and moral duty to patients, colleagues, the profession of nursing, and the community to take action. Documents such as the American Nurses Association Code of Ethics for Nurses provide a framework for patient safety.

Consider the following:

• Do not ignore poor performance.
• Do not lighten or change the nurses’ patient assignment.
• Do not accept excuses.
• Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy.

Treatment

Nurses who seek treatment have a good opportunity for successful recovery. Treatment can be effective in reducing substance use and improve health, social, and occupational well-being. Many organizations offer alternative treatment programs instead of drastic action such as termination.

Currently 37 states offer some form of a substance abuse treatment program to direct nurses to treatment, monitor their re-entry to work, and continue their license according to the National Council of State Boards of Nursing. Alternative programs monitor and support the recovering nurse for safe practice. Strong recovery programs offer a comprehensive, bio-behavioral, individualized treatment plan. The phases include in-treatment or outpatient detoxification in a safe environment; education about the disease; group, individual, and family therapy; and most important a relapse prevention program. However, boards of nursing have a responsibility to safe guard the public, so they may suspend the nursing license of an identified impaired nurse if they suspect he or she may pose a danger to patients.

The American Nurses Association (ANA) is a strong supporter of alternative or peer assistance programs that monitor and support safe rehabilitation and the eventual return to the professional workforce. While relapse is high, the goals for the substance-abusing nurse is to seek treatment, reach recovery, and re-enter the workforce.

Costs of substance abuse

Substance abuse is costly to the individual nurse, their friends and families, and healthcare organizations in terms of loss of income, health, and relationships, and diminished quality of care provided to patients. While it may be difficult or uncomfortable, individual nurses can make a positive difference when they identify substance-abusing nurses so that they can get the help they need.

Substance-abusing nurses most likely will not seek treatment until confronted by peers, family, or nursing management, or their employment is in jeopardy. However, those who enter and complete structured treatment programs can be successful and reenter the profession of nursing.

Cynthia M. Thomas and Debra Siela are assistant professors of nursing at Ball State University School of Nursing in Muncie, Indiana.

References

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