Work pressures can make ICU nurses vulnerable to substance use
Study says incidence higher in critical care
While nurses as a whole don't abuse alcohol and drugs more than the general population, nurses in the critical care environments tend to rank high among specialties that use those substances, according to a newly released study.1
The study, published in the American Journal of Public Health, focused on substance use, not abuse, but concludes that the issue is a serious problem that threatens careers and the quality of patient care, says lead author Alison M. Trinkoff, ScD, RN, associate professor in the Department of Psychiatric, Community, and Adult Primary Care Nursing at the University of Maryland School of Nursing in Baltimore. It raises sobering questions about how stress, drug availability, and even personalities play a role in substance use in critical care nursing.
The study found that 32% of 4,438 registered nurses responding to an eight-page anonymous mailed survey had used marijuana, cocaine, or prescription-type drugs, or had engaged in binge drinking or smoking at least half a pack of cigarettes per day at some time in the previous year.
The study does not indicate what portion of the 32% might have a substance abuse problem, and Trinkoff says she is examining data from the survey for a subsequent report. Among nurses who reported substance use during the previous year, 4% had used marijuana or cocaine, and 7% had used prescription-type drugs, such as amphetamines, opiates, sedatives/hypnotics, or tranquilizers. Binge drinking was reported by 16% and cigarette smoking by 14%.
A unique factor in this study is that it measured substance use by nursing specialty. For all substances combined, oncology nurses reported the highest past-year prevalence (42%), followed by psychiatry (40%), and adult critical care and emergency (both 38%).
For marijuana/cocaine use, emergency and pediatric critical care nurses had the highest rates (7%), followed by adult critical care nurses (6%). For purposes of comparison, a subgroup of 702 nurses was designated as a reference category. This subgroup was composed of specialties with the lowest substance use rates: women's health, general practice/school/occupational, and general pediatrics. The reference group rate was 2%.
Prescription-type drug use was less varied across specialties, with oncology (9%), rehabilitation (9%), and psychiatry (8%) reporting the highest rates, compared with 5% in the reference category.
Binge drinking was highest among oncology (26%), emergency (25%), and adult critical care (22%) nurses. The reference group rate was 11%.
The highest rates of cigarette smoking were reported in the specialties of psychiatry (23%), gerontology (18%), and emergency (18%). Lowest smoking rates were reported by pediatric critical care nurses (8%), a lower rate even than the reference group at 10%.
The data regarding prescription drug use "doesn't necessarily mean that people would be using drugs from the workplace, but it just might mean that if you're using a lot of drugs to help people, you might get a little bit of a comfort with it," says Trinkoff. "You might be very familiar with different drugs and how they work, so maybe it would eliminate a barrier that some people in the general population would have when it comes to using these things on their own. Access is a definite risk factor."
The study suggests that substance use is not random across nursing. Factors such as stress, working conditions, and access to drugs can create a higher likelihood of substance use in certain specialties. Other predisposing factors might relate to personality traits of people who enter certain specialties. For example, studies have shown that critical care or emergency personnel are more likely to be "sensation-seekers" who crave crisis exposures.2,3
One purpose of the study was to look for predictors of potential substance problems. "We have a fair amount of data in the literature on nurses who are in treatment [for addiction] and what those people look like, but we don't really have much on what we can notice early on in terms of predictors or factors we can associate with use that can ultimately become problem use," Trinkoff says.
The stress that comes with managing critical patients is one obvious issue to look for. Generally, people who work in high-stress areas where psychological and emotional strain abound tend to use drugs more than others, says Madeline Naegle, RN, CS, PhD, FAAN, an associate professor at New York University's division of dursing in New York City. Naegle coordinated an American Nurses Association task force on impaired nursing practice that examined how health professionals deal with members who develop substance abuse problems or psychiatric illness.
But work stress is only one part of the story, she says. Three major factors contribute to why anyone tends to become a substance user:
r psychological makeup;
r family history and constitutional factors (genetic predisposition);
r environment.
For nurses, one major factor in the third category is the availability of drugs - particularly prescription drugs such as analgesics/narcotics - and the attitude many health professionals develop that self-medicating is an acceptable way of relieving psychological pain.
Naegle also says that managed care cutbacks have downsized the nursing force in many hospitals, forcing nurses to work overtime and significantly increasing workloads. Hospitals are reducing the numbers of registered nurses and adding unlicensed personnel and nurses' aides, "which adds more bodies, but the registered nurses must supervise those people."
A negative impact of downsizing
Nurses surveyed in the substance use study "are a small portion of a large number of nurses, all of whom are feeling the negative effects of downsizing in the form of dropped nurse-patient ratios - fewer nurses to greater numbers of patients," she explains.
While stress alone does not cause addiction, it sometimes causes people to use more if they already are users. Individuals who smoke or drink or self-medicate may increase their behavior due to stress.
"People tend to use drugs as a chemical coping mechanism," she says.
The problem is that hospital budget cuts under managed care have decimated the resources that provided nurses with emotional and psychological support systems.
"It's important for nursing and hospital management to hear the message, and that is about the fact that we have eliminated things that nurses experienced as supportive in their work environments as a function of cost-cutting," she states. Those include employee assistance programs, continuing education hours that nurses could use to go off-duty for conferences, and tuition reimbursements that allowed nurses to obtain degrees. The latter means "they're stuck at a certain job level rather than being able to improve themselves, which creates frustration."
An advisory board member for an employee assistance program network in New York City metropolitan area hospitals, Naegle follows health care trends closely. "One thing is very clear," she says, "and that is that stress and strain in occupational situations have increased since managed care and cutbacks in hospital resources have decreased employee assistance programs."
Take steps to organize support systems
Employees who want help then are forced to ask for an outside referral, which is often difficult for nurses, who are supposed to be "tough," she says. "They deal with patients who are traumatized and dying every day, so the struggle is, `Do I have a right to talk with someone about it. Is it me? Am I not handling this well?' If there is no one to talk to, what happens to feelings that are aroused in the workplace that have to do with being overburdened, working too hard, dealing with loss, or dealing with rapid-fire trauma such as we see in the emergency rooms? How does the individual process all those feelings at the end of a shift?"
Despite budget cutbacks, Naegle says managers can implement a number of support systems for nurses:
r Combine forces with other area hospitals to sponsor continuing education programs or bring in speakers for a group of hospitals to create a day of learning for a group of nurses. "They can charge a small fee, and it will pay for itself in many ways," she says.
r Create on-site educational programs that are part of employee orientation about the use of drugs and their health implications. Provide information, for example, on what drinking does to one's health and what is a healthy level of drinking. Several government agencies provide free brochures and handouts. Also provide information on community resources for help with substance abuse.
r Provide information on state nurses' associations' peer assistance programs that provide outreach and help for substance abuse problems.
r Form workplace support groups that deal with stress in general. Groups can be led by other hospital personnel, such as a counselor from the mental health or social work department. Post notices around the hospital publicizing the groups. "It can be an effective way for people to unburden themselves about the stresses of the day," Naegle notes.
r Encourage alternative methodologies for dealing with stress, such as imagery, relaxation exercises, massage, meditation, and physical exercise. Naegle says one administrator offered employees free introductory six-month memberships to a health club near the hospital.
r Look at nurse-patient ratios, especially in areas of high patient acuity where more registered nurses are needed.
"When we don't have that, the quality of care suffers, and the nurse ends up absorbing the stress by trying to uphold standards," Naegle maintains. "In areas where there's high acuity, and in areas where there are high emotional strains, there's more substance use. That's pretty important information."
References
1. Trinkoff AM, Storr CL. Substance use among nurses: Differences between specialties. Am J Public Health 1998; 88:581-585.
2. Zuckerman M. Sensation Seeking: Beyond the Optimal Level of Arousal. Hillsdale, NJ: Lawrence Erlbaum; 1979.
3. Hafner RJ, Proctor N. Student nurses' specialty choice: The influence of personality and education. Contemp Nurse 1993; 2:38-43.
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