ILLNESS VERSUS MORAL FAILURE

Recovering from chemical dependency is a life-long process, and some individuals require more than one round of treatment to be successful. Most states and employers recognize substance abuse as a disease that requires treatment. (18) Alcohol abuse and other drug addictions are recognized as medical conditions with corresponding ICD-9 codes. Despite this classification system and the growing awareness of the illness, shame is still associated with addiction. Nurses who abuse substances are stigmatized by their colleagues and society. (19) "Blaming, scolding, or punishing, however, really have no place in the treatment of any illness." (11(p128))

The stigma that addiction is a moral failure or lack of willpower rather than a disease is pervasive and embedded in the fabric of US society, "and when the addict is a nurse, the stigma is even greater." (1(p27)) Society, in general, views nurses as angels of mercy; nurturers par excellence; or the lily-white, starched presence of yesterday's movies. Being placed on such a pedestal has its consequences when a nurse becomes a "fallen angel." Society and other health care professionals are quick to demonize this fallen angel as a "'bad person' who now steals our grandmother's pain pills." (11(p111))

Health care professionals are more harsh and punitive toward colleagues who abuse substances than they are toward others in the general population. (10) This phenomenon probably occurs because health care professionals are perceived to be highly educated, responsible people who have earned a position of trust with patients and patients' family members. (10) Nonabusing nurses often have moralistic, stereotypical, and pessimistic views about addiction. One explanation for this harsh view is that nurses expect perfection from themselves and their coworkers because they hold patients' lives in their hands. (1,20) One survey found that nurses perceive individuals who have substance abuse problems as immoral and as having character defects with low probability of recovery. (20) Nurses who have substance abuse problems, therefore, carry the stigma associated with this breach in professionalism.

Embracing the concept that addiction is a definable medical illness is imperative. Nurses are people with failings like everyone else. Removing the stigma associated with substance abuse will make it easier for nurses to seek treatment and disarm the code of silence that exists on nursing units. (19)

SIGNS AND SYMPTOMS

Although some nurses may be successful at disguising or hiding a drinking or drug problem, employees familiar with substance abuse are more likely to detect it in others. (4) Signs and symptoms exhibited by nurses who have substance abuse issues are listed in Table 2. Many of these signs and symptoms are general and nonspecific, but when an individual's behavior is analyzed over time, the picture becomes clearer.

Nurses who abuse substances become financial liabilities to their employers because of increased use of health benefits, absenteeism, workplace accidents and associated workman's compensation and disability claims, theft and security problems, and decreased productivity and high turnover rates. Serious relational (ie, hidden) costs include lower morale and poor communication within the department and diverted supervisory and managerial time. (2,4,21,22)

Nurses with alcohol dependency tend to drink before their shift, during lunch and coffee breaks, and in the bathroom. (5) Some nurses may abuse cough syrup and mouthwash, which are readily available on most units. (5)

Nurses who abuse drugs may support their addiction with prescription medications. Undiverted prescriptions are obtained when a nurse asks a staff physician to write a prescription. Nurses who abuse drugs also forge prescriptions. (5) Diverted prescription medications come either directly from patients or from the unit's medication dispensing system. (5) For example, sterile water or saline can be substituted for a patient's dose when the medication is clear. The nurse then gives the remaining dose to the patient and saves the difference for his or her own use later. The nurse also may administer a partial dose to a patient and save the difference for his or her own use. Nurses also may self-administer wasted medications, which can happen when a colleague cosigns the narcotics record regarding a wasted medication without actually witnessing the medication being wasted. (5)

Other ways to divert medications include signing out medications for patients who are transferred or discharged from the unit or signing out doses of as--needed medication for patients who have not requested the medication or who may have refused it. (5) Nurses also have been known to back date medication records, alter physicians' orders, or write a verbal order for a medication without a physician's authorization. (5)