REASONS TO REPORT AN IMPAIRED NURSE

Substance abuse issues in nursing usually are first noted by staff members. Whether a staff nurse acts on his or her knowledge or chooses to remain silent directly affects patient care and safety and the reputation of the institution. It also ultimately affects the impaired colleague's level of functioning. The path of least resistance (ie, dismissing a suspicion) is much easier to follow than contending with suspicious behaviors. (11) Nurses should understand that if addicted nurses are not helped, they are in danger of harming patients, the facility's reputation, the nursing profession, and themselves. (17) The consequences of not reporting concerns can be far worse than reporting these issues.

Problems related to substance abuse usually do not surface on the job until long after the problem has begun. By the time a nurse demonstrates negative or inappropriate work habits, the problem already has reached a serious staged. (5,11) "Usually, by the time a nurse is caught and confronted, most of the people in the unit knew" (23(p148)) there was a problem. Nurses need to talk more among themselves and examine their complicit code of silence (ie, the "don't talk rule") that permeates their nursing units. In the long run, "perpetuating the code of silence will only undermine the public's trust in nurses." (24(p11)) It is incumbent upon institutions to create systems that allow for reporting and tracking substance--abuse incidents and provide education and support to help nurses participate in rehabilitation and avoid placing patients in harm's way.

Nurses have an ethical and legal obligation to report colleagues whose activities could or do harm patients. "Patients, who are vulnerable, have the right to safe, skilled care administered by a nurse who is mentally and physically able to perform certain nursing duties." (25(p21)) Nurses also have an obligation to protect the organization in which they work by reporting impaired practice when it is observed. (25) In some states, remaining silent can result in charges against the nurse who knew something but did nothing because this nurse supported an environment that permitted a colleague's negligence or malpractice. Remaining silent violates a nurse's ethical duty to safeguard patient care. (18)

According to the ANA, nurses are responsible for responding when a colleague is exhibiting questionable practices. The ANA proposes that nurses help impaired colleagues obtain assistance by reporting suspicions or events to appropriate personnel in the employment setting. It is nurses' "responsibility to respond to a coworker's questionable practice as an advocate for the patient." (26(p24))

A second major reason to report a nurse who behaves in a suspicious manner is to help that person. People who are entangled in their addiction sometimes need help acknowledging and accepting treatment. Reporting a colleague actually could help save his or her life. Another reason to report an impaired nurse is to help keep that nurse in the profession after he or she has gone through rehabilitation. On another level, nursing professionals, as members of the caring trade, should help one another overcome personal obstacles.

A survey demonstrated that the severity of an incident was an important piece of information nurses used in deciding whether to report a peer. (27) For example, if a patient did not receive his or her requested pain medication but was unharmed (eg, no increase in blood pressure or pulse with resulting symptoms), a nurse may be reluctant to report the incident. If, however, the patient then tried to get out of bed, fell, and was injured, this same nurse would feel compelled to report the incident to the manager. Additionally, the respondents stated that they also considered whether the nurse usually was a good care provider along with potential repercussions to the nurse if he or she was reported. (27) In other words, many nurses do not report behaviors they find suspicious because they do not believe that the incident was severe enough to report, or they believe that the nurse is a good care provider. Just as near misses should be reported, however, so should all suspicions about another nurse's behavior be documented and reported to the nurse manager. Only as time passes will the weight of the documentation be shown to be relevant or irrelevant. In the meantime, there is no harm in collecting information.

REASONS NURSES Do NOT REPORT

An interesting question is why nurses who are aware of other nurses' substance abuse problems choose not to report or find themselves unable to intervene. First and foremost, friendship acts as a barrier to recognizing and addressing deviant nursing practice. Friendships makes it is easy to look the other way and deny that a problem exists. Loyalty can be a major obstacle to reporting incompetence, particularly in departments that have a strong team spirit. (17)

Some nurses may fear being a hypocrite, particularly if they also indulge in alcohol. Going out for a drink after work with nursing friends is an accepted social phenomenon in the United States. (17) A nurse who is suspicious of another nurse may feel guilty reporting a potential problem because he or she also is one of the group having a few drinks after work. The distinction, however, is the extent and degree to which a nurse drinks and the level of accountability associated with the behavior. (17)

One example in the literature shows how nurses dismiss concerns about a friend. These nurses told themselves that patients had not been harmed and that there was no failure of duty. (17)

   Many coworkers observe
   unsafe behaviors but are
   reluctant to report nurses
   with whom they work
   closely and whose personal/professional
   concerns
   they understand. (9(p38))

This occupational subculture, in which employees either bend rules or view certain behaviors as normal rather than deviant, does persist. (4)

Nurses also may not report other nurses for fear of being perceived as snitches or labeled as whistle-blowers. These nurses may be concerned about retribution for reporting, such as having their own work scrutinized and criticized. (27) Some nurses do not want to become involved because confronting someone who may become angry, deny the problem, or plead for another chance can be difficult. Furthermore, nurses who know other people with substance abuse problems already are aware that impaired nurses are good at manipulating people and can distort relationships and block communication. (15) They may question the value of getting involved and expending energy dealing with the issue.

In one study, 91% of survey respondents said they would report an incident that either harmed patients or put them at risk. In reality, however, only about half actually reported all the incidents they had seen. (27(p37)) Most nurses are not educated about how to recognize or intervene with a nurse who is abusing substances. This lack of knowledge contributes to self-doubt about the scenario the nurse has witnessed. Insecurity fosters an environment that enables an abusing nurse to continue and prevents colleagues from documenting and reporting the suspicion. (6) This passive environment condones the code of silence.

   Embedded in nursing culture is the
   practice of covering up for a colleague
   with a perceived problem, which can
   actually exacerbate the original problem
   rather titan help the individual
   concerned. (28(p3))

   [This] traditional avoidance of honest
   confrontation not only allows but
   encourages both the substance abuse
   and the degree of impaired practice to
   grow worse. (17(p48N))

Just as individuals deny problems, many health care facility administrators deny that alcohol or substance abuse is a significant problem in their organization. (11(p111)) Rather than deal with issues directly, many organizations dismiss or terminate employees with addictive issues without reporting them or providing treatment. These nurses then can apply for employment elsewhere, and their slate is wiped clean. Even when contacted by the new place of employment, previous employers may leave out pertinent information about the employee being discussed.

   Some employers say they
   have become reluctant to
   provide other employers
   with frank evaluations of
   former, and even fired,
   employees,for fear of libel
   suits.... (24(p11))

The result is that impaired nurses can move from job to job without being detected.

Other reasons nurses choose not to report an impaired colleague include fear of being sued, belief that the supervisor will dismiss the information provided, or self-doubt. (29) Compounding these issues is the fact that the law is not very forgiving. A nurse can be a good nurse for 25 years, but if he or she makes one serious mistake, the board of nursing may call it incompetence, which could culminate in the nurse losing his or her license. If the end result could be a termination of employment, arrest, or prosecution with prolonged loss of license, nurses will be less inclined to report an impaired colleague. (15) Reporting could bring shame and social disruption into that nurse's life and have a negative effect on the nurse's livelihood, family life, and career. There is a pervasive belief that reporting a nurse to the state board of nursing will only result in disciplinary action, not treatment. (11) Given the potentially serious consequences of reporting a colleague, some nurses question whether there are situations that justify not reporting. (27) Not surprisingly, reporting an impaired colleague is not a role that is easily embraced.