ADDICTION IN THE NURSING POPULATION

The prevalence of alcohol and drug abuse in the nursing population has not been fully documented, but it is believed to parallel that of the general population. It is suspected that 10% of the nursing population has alcohol and/or drug abuse problems, and that 6% of nurses have problems that are serious enough to interfere with their ability to practice. (5) The American Nurses Association (ANA) has estimated that 6% to 8% of nurses use either alcohol or drugs to an extent sufficient to impair their professional judgment. (6) Among nurses, prescription-type medication use has been noted to be higher and marijuana and cocaine use has been noted to be lower than in the general population. (7,8) Statistics show that nurses are more likely to practice sobriety compared to people in other occupations. (9)

A major underlying reason for substance abuse among health care professionals is related to family histories that include emotional impairment, alcoholism, drug use, and/or emotional abuse that results in low self-esteem, overachievement, and overwork. (10) This environment can produce individuals who help troubled family members either in a positive (ie, nurturing) or negative (ie, enabling or co-dependent) manner. (10) It also has been noted that people in the helping professions, particularly nurses, have significantly higher incidences of alcoholism in their families of origin. (11) In one study, family alcoholism contributed to alcohol abuse in approximately 80% of nurses who had an alcoholic family member. (12)

Many nurses are adult children of alcoholics and, therefore, are prone to interact with other dependent people in ways that are considered enabling. Although the enabler's behavior may be well intentioned or unwitting, the enabler ignores or covers up the signs that something is wrong and accepts unlikely excuses. (11) Indeed, children in alcoholic families learn that drinking alcohol to excess is normal behavior. (12) Health care professionals who fit this description may be attracted to nursing careers because of the opportunity to continue in a care-giving role. (10)

Stress in the workplace provides another explanation for why some nurses abuse substances. Increased workloads, decreased staffing, double shifts, mandatory overtime, rotating shifts, and floating to unfamiliar units all contribute to feelings of alienation, fatigue, and, ultimately, stress. (4,13) Substance abuse may be a way of coping in jobs perceived as alienating. Nurses may deal with these issues because they have no choice or because they are workaholics and are addicted to their careers--they live, breathe, and sleep work. (1)

Finally, health care professionals are at risk for drug abuse because of the availability of medications in the workplace and the cultural acceptance within nursing that pharmacologic agents provide a desirable method to cure one's ills. Health care provides a permissible climate in which to use exogenous substances to correct internal feelings or illnesses. (14) Nurses have been taught that medications solve problems. They have seen medications alleviate pain, cure infections, and diminish anxiety. Not only are prescription medications accessible, but nurses also have a mistaken belief about their personal skills and level of knowledge to self-medicate without becoming addicted. (15,16) Self-medicating behaviors may only be viewed as inappropriate when the magnitude and regularity of these behaviors increases. Access creates a familiarity with controlled substances that can increase the likelihood that nurses will use them on their own. Nurses may erroneously believe that they have the ability to control and monitor their own use of medications because of their experience with administering medications and observing their effects on patients. (8) Some nurses "believe that they are immune to the negative consequences of drug use because they are so familiar with drugs." (7(p581))

A health care professional's impairment can be further exacerbated by overwork, sleep deprivation, a poor social life, and financial problems. (10) Nurses who have been dependent on chemical substances have described some factors that led to their problem, including

* psychological or physical pain,

* emotional problems too complex to handle, and

* a demanding, high-pressure, and stressful work environment. (12)

Nurses also may have difficulty admitting their own problems. In general, nurses who abuse substances often are well-liked and respected, bright and highly skilled, and ambitious and achievement-oriented. (12) These nurses are in demanding jobs that involve responsibility and require commitment. Evidence demonstrates that nurses who abuse alcohol "tend to be achievement oriented people who strive to be 'super nurses' at work and 'superwomen' elsewhere." (12(p79)) Although nurses who abuse substances may seem to have everything under control, they often have a history of

* family problems,

* previous emotional or mental health problems,

* family members with chemical dependency, or

* sexual trauma. (5)

Although several studies have shown that nurses may not have a higher risk of abusing substances than the rest of society, (7) there may be subgroups within nursing that are more prone or vulnerable to abusing substances. Exposure to death and dying, demanding jobs, lack of education on alcohol and medication hazards, and burnout take their toll on nursing staff members. (7) Different nursing specialties have different personnel selection factors, demands in the work setting, and availability of controlled substances.

Nurses who work in critical care settings (ie, emergency departments [ERs], intensive care units [ICUs], ORs, postanesthesia care units), for example, report more prescription-type substance abuse and easier access to substances in the workplace than non critical care nurses. (7) One study demonstrated that ER and ICU nurses were more likely than their peers to report using marijuana and cocaine and binge drinking. (7) A theory for this finding is that people who work in these departments are more likely to have a "sensation-seeking" personality trait that embraces exposures to crisis situations. This trait actually has been identified on the genetic marker as an impulsivity gene. (7)

Other factors that may result in an increase in substance use for ER and ICU nurses include increased frequency of dealing with death, unpredictable work pace, the immediacy of the nursing intervention, reliance on pharmacologic agents, heavy work demands, and ready access to controlled substances. (7) Working on a critical care unit is technically and emotionally demanding. Patients die unexpectedly, which can make a nurse feel that he or she has failed. Work demands also can extend beyond the limits of a nurse's professional preparation, and on-the-job training can be insufficient to reassure him or her of competence, which results in high stress levels. (17)

Nurses who work in oncology also have high overall substance use rates, particularly with binge drinking. (7) One theory for this behavior is that alcohol consumption serves as a coping mechanism to help nurses distance themselves from the emotional pain they experience while working with patients who have cancer. (10) Psychiatric nurses also experience high levels of substance use, and this practice is heavily oriented around pharmacologic agents. (7) Nurses working in psychiatric areas may consider self-medication more acceptable because they work in a culture that accepts using psychotropic medications to cope with life. Additionally, psychiatric nurses may be more willing to report their use of substances than other specialty nurses because they perceive this as an acceptable form of treatment. (7)

Pediatric and women's health nurses report the lowest use of addictive substances. (7) This could be due to the lack of availability of these substances on their units, or it could be that this population of nurses is emotionally expressive. People who are able to express their feelings may have less need for substance use. (7)