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What is the issue?
The issue is substance abuse and substance abuse disorders in nursing. The development of a substance abuse disorder occurs when nurses are unable to cope with the high levels of stress and responsibilities while working. Trinkoff, Yoon, Selby, Storr, Edwin, & Baek (2021) stated that unchecked work characteristics can lead to negative health effects like substance abuse. Substance abuse can go unrecognized in nurses who are abusing substances. This puts patients at risk for harm and co-workers at risk (NCSBN, 2020).
Who is affected?
The nurse who is involved in substance abuse faces legal and ethical issues. The impairment of the nurse puts patients at risk for harm while co-workers have a legal, ethical, and professional responsibility to report their co-worker for showing signs of substance abuse (NCSBN, 2020).
How?
Nurses can develop issues with substance abuse due to of the high level of stress they are faced with in this type of work environment. Substances are used by many to cope with stress and negative emotions (Trinkoff, Yoon, Selby, et al., 2021).
Where?
Nurses are at risk when working in any healthcare clinical setting that may exacerbate risk factors that lead to substance abuse (Trinkoff, Selby, Han, et al., 2022).
When?
Nurses are at risk for developing substance use issues as early as while completing nursing school due to the newly created high stress levels from completing course work and caring for patients. Also, Patients are at risk for harm when nurses are impaired while providing care (Trinkoff, Yoon, Selby, et al., 2021).
Why?
According to Trinkoff, Yoon, Selby, Storr, Edwin, & Baek (2021), nurses are at risk for developing substance abuse because of the lack of education surrounding substance abuse especially starting as a student nurse. Many nurses do not know the proper signs to look for that indicate substance abuse. Co-workers can also be worried about reporting someone because of the stigma surrounding substance abuse and fear that their co-worker may lose their job and their license to practice.

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Awareness of Workplace Signs
There is a lack of knowledge about how to recognize signs of substance abuse due to the lack of education starting first in nursing school. When student nurses are taught about the signs to look for as well as how to report the issue it leads to a better chance to get the nurse with substance abuse into a treatment program and get them the help they need (Trinkoff, Yoon, Selby, et al. 2021).

Prevalence of Substance Abuse

According to Trinkoff, Selby, Han, Baek, Steele, Edwin, Yoon, & Storr (2022), for registered nurses the,"prevalence of prescription drug misuse was more than twice as high as the general population".

The Nurse Worklife and Wellness Study concluded that 5.7% of nurses in the study had used illicit drugs in the past year and 9.9% of those nurse misused prescription-type drugs. The highest rates of substance abuse occurred in nurses working in home health and hospice care at 19% and nursing homes at 15.8%. The overall amount of nurses were screened for substance abuse and were positive was 18% (Trinkoff, Selby, Han, et al., 2022).

Components of Monitoring Programs

In the past, substance abuse was greatly stigmatized and many nurses where afraid to report their co-workers who showed signs of substance abuse issues. Co-workers were afraid to report other co-workers out of fear that the nurse may be fired, lose their license, or face legal disciplinary actions.

Today, many state boards of nursing utilize a nondisciplinary approach to treating nurses with substance abuse disorders known as alternative-to-discipline programs (Russell, 2023).

These programs include a nurse monitoring program that is made of up to 21 categories. Some of these requirements to completing the program include abstinence from alcohol and drugs, a change in work hours and shifts, frequent toxicology screenings, participation in therapy and medication-assisted therapy, and participation in group meetings like Alcoholic Anonymous or Narcotics Anonymous to name a few (Russell, 2023).

Components of these programs include static and dynamic components (Russell, 2023).

Static components are consistent with all participants and include noncompliance and relapse.

Dynamic components differ among participants and are individualized. It includes the treatment program, length of program, peer support, meetings, therapy, and workplace restrictions.

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Current role of the nurse

The current role of the nurse is to be able to recognize the signs of substance abuse that their co-workers may be exhibiting including:

Frequent medication errors

Wasting medications frequently

Taking long breaks and having many absences

Diverting medications away from patient use

Early recognition of these signs are important in order to get the nurse who is abusing substances into a treatment program quickly. This prevent endangering patients and their safety as well as moving the nurse to another lower risk units where they can be monitored (Trinkoff, Yoon, Selby, et al., 2021).

It is also the nurses job to report their co-worker to a supervisor or the state board of nursing. This can be done anonymously so that the nurse who is being reported does not have any knowledge about who reported them.

Has this improved or exacerbated the issue?
According to Trinkoff, Yoon, Selby, Storr, Edwin, and Baek (2021), the results of the study they completed show that, "almost all nurses (93%) agreed that they would tell their supervisor if they thought a colleague had SUD". Nurses are put at ease knowing that there are treatment programs to help nurses with substance abuse disorders keep their jobs and license to practice while receiving the help that they need. In the study conducted by Trinkoff, Yoon, Selby, Storr, Edwin, and Baek (2021), this issue can be exacerbated because 58.5% of nurses expressed concern about a co-worker getting fired or punished for their actions.

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NCSBN Substance abuse disorder pamphlet

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Guidelines for Monitoring Substance Abuse in Nurses

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Involvement of the nurse
According to the National Council of State Boards of Nursing (2020), nurses play a vital role in helping to identify nurses with substance abuse issues. Nurses need to know the difference between stress-related behaviors and signs of impairment so they can move those nurses into the proper course of treatment. These include behavioral changes, physical signs, and diverting drugs. The National Council of State Boards of Nursing (2020) has stated, "the earlier an SUD in a nurse is identified and treatment is started, the sooner patients are protected and the better the chances are of the nurse safely returning to work".

"You need to acknowledge that health care professionals are not immune to developing an SUD and you should ignore the stereotypes of what a 'typical' person with a SUD looks like" (NCSBN, 2020).

Attached to the presentation is a pamphlet titled "A Nurse's Guide to Substance Use Disorder in Nursing" (NCSBN, 2020).

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National Council of State Boards of Nursing

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Curricular Concepts
1. Medication Administration
Safe medication administration is important for all nurses. Nurses need to know the rights of medication administration. These include the right client, right medication, right dose, right time, right route, right documentation, right client education, right to refuse, right assessment, and right evaluation (ATI, 2019). When nurses know how to properly administer medications then nurses can prevent medication errors. Knowing the rights of administration can also help nurses to spot signs of medication diversion.
2. Assessing for Substance Abuse Disorders
There are factors that place nurses at risk for substance abuse. Some of these factors are working in high stress environments, knowledge and easy access to drugs, family history of substance abuse, and coping mechanisms. A nurse can assess a co-worker for drug impairment by carefully monitoring the nurses actions, discuss what you have observed with a supervisor, and speak with the co-worker about errors they may have recently made.

Leadership Role
These concepts have prepared me to take a leadership role after transitioning from student nurse to newly licensed nurse. Throughout my time in this nursing program I have learned so much about medication administration. Wasting medications properly and monitoring medication counts within the Omnicell are key ways to prevent and monitor medication errors. Being knowledgable about the signs of substance abuse disorders as well as how to assess for them can help to keep patients safe and help nurses with substance abuse disorders to get proper treatment in a timely manner.

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1. Breaking the Stigma
Education on how to recognize signs of substance abuse should start with student nurses while in their nursing program. This prepares new nurses on the behavioral changes and physical changes to look for in order to report these findings quickly. According to the National Council of State Boards of Nursing (2020), nurses who are preoccupied or concerned with their own responsibilities may not always recognize the warning signs. When taught which signs to look for it can make it easier to recognize these signs and report them to a supervisor or the state board of nursing (Trinkoff, Yoon, Selby, et al., 2021).
2. Know the Signs Associated with Substance Abuse Disorders
Substance abuse can affect anyone and doesn't just affect one type of demographic. It affects individuals of all ages, genders, and backgrounds. Knowing what signs to look for can help to identify the issue sooner and help get the nurse into treatment and keep patients safe. Some of these signs include:

Changes or shifts in job performance, absences from the unit for long periods of time, frequent bathroom trips, arriving late and leaving early, making many errors.

Changes in appearance, increased isolation, inappropriate verbal or emotional responses, and alertness that is diminished.

Diversion of medications, incorrect narcotic counts, increased wasting of narcotics, reports from patients about ineffective pain relief, altered medication orders, and variations in discrepancies of controlled substances (NCSBN, 2020).

3. Be Supportive
Some nurses believe that they don't have to report a co-worker with a substance abuse disorder and that they can help them on their own. This course of action is not supportive to the nurse with a substance abuse disorder. It is best to show support by reporting the issue which in turn leads to a supervisor or the state board of nursing to place the nurse in a treatment program that has the proper resources to help the nurse (Trinkoff, Yoon, Selby, et al., 2021).

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Barriers to involvement
Barriers that other nurses face when reporting nurses with substance abuse issues include a lack of knowledge on what to report and how to report it and fear that they will cause the nurse to lose their job or get into legal trouble. Nurses are faced with an ethical dilemma related to their emotions about reporting a co-worker and getting them in trouble or not reporting a co-worker and not keeping patients safe from harm (Trinkoff, Yoon, Selby, et al., 2021). In the past, nurses with substance abuse disorders would be fired from their jobs and lose their nursing license which has led to a stigma around reporting. There is this social implication that people who abuse drugs look and act a certain way but that is not the case. Individuals who abuse drugs can be from all backgrounds of life (NCSBN, 2020).