Managed care cutbacks slash support for nurses
Increased stress can lead to more substance use
Occupational strains and stresses have increased with the advent of managed care and hospital downsizings, but budget cutbacks have left nurses without the support systems that can help prevent substance use and abuse, says a national expert on mental health and addictions among nurses. However, occupational health departments can play an important role in helping nurses prevent and find help for substance abuse.
A recent study revealed that nurses in certain specialties - such as oncology, psychiatry, and emergency - are more likely to use alcohol, tobacco, and other drugs than are nurses in certain other specialties.1 While the authors did not pinpoint job stress as the main cause of substance use, they did acknowledge it as a contributing factor.
Generally, people who work in high-stress areas where psychological and emotional strain abounds tend to use drugs more than others, says Madeline Naegle, RN, CS, PhD, FAAN. An associate professor at New York University Division of Nursing in New York City, Naegle coordinated the institution's advanced practice nursing psychiatric and mental health program, developed a curriculum in addictions, and directed the faculty development program in addictions. She also coordinated the American Nurses Association's 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 someone becomes a substance user: a person's psychological make-up, family history and constitutional factors (genetic predisposition), and their 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 medicating oneself is an acceptable way of relieving psychological pain.
A psychological factor might be that people who have mental health or addiction problems in their families tend to choose to become health professionals, "but this has not been very well-studied, so we don't really know," says Naegle, who also has a private counseling practice in which one-third of her clients are registered nurses.
When examining whether nurses in certain specialties tend to become users, psychiatric symptoms must be considered because many people use drugs to medicate unpleasant feelings such as depression and anxiety, she explains. In some occupational environments, such as an oncology department where nurses are caring for dying patients but have no place to talk about the strain of their work, substance use can become a ready solution.
Naegle also says 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."
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 things 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."
Handling feelings at the end of a shift
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 hospitals can implement a number of support systems for nurses, many of which are appropriate to be organized by occupational health departments:
· Combine forces with other hospitals in the same region or area to sponsor continuing education programs or bring in speakers for a group of hospitals instead of only one 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.
· Create on-site educational programs that are part of employee orientation about the use of drugs and their health implications. For example, provide information on what drinking does to one's health and what a healthy level of drinking is. Several government agencies provide free brochures and handouts. (See editor's note at end of article.) Also provide information on community resources for help with substance abuse.
· Provide information on state nurses' associations' peer assistance programs that provide outreach and help for substance abuse problems.
· Form workplace support groups that look at 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 group. "It can be an effective way for people to unburden themselves about the stresses of the day," Naegle notes.
· Encourage alternative methodologies for dealing with stress, such as guided imagery, relaxation exercises, massage, meditation, and physical exercise. Naegle says one administrator had the right idea when he offered employees free introductory six-month memberships to a health club near the hospital.
· Work on changing the cultural norms in nursing regarding the use of tobacco, alcohol, and drugs. Help nurses learn that using is dangerous and when use becomes abuse. Make it difficult to use (example: hospitals banning smoking). Don't serve alcohol at hospital parties. Help to change people's thinking about what is acceptable.
· Occupational health nurses need to become comfortable talking to employees about their substance use "and presenting it in such a way that people feel they can talk about their use without fearing that they will be labeled as an addict," she states. "[Occupational health nurses] often don't know where to refer a person or what kinds of suggestions to make, but they can really counsel a person about alcohol use if they know themselves what a healthy level of alcohol use is. There are guidelines and information prepared by the federal government, and it's all free."
While some hospital occupational health departments might not be able to afford to develop special programs, they can work with existing employee assistance programs in their region to make information available to employees.
Finally, employers must 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, such as in the emergency room, and in areas where there are high emotional strains, such as in psychiatry and oncology, there's more substance use. That's pretty important information."
[Editor's note: For more information, statistics, and studies about drug and alcohol use and abuse, contact the following organizations:
· National Clearinghouse for Alcohol and Drug Information, (800) 729-6686; http://www.health.org.
· National Institute on Drug Abuse, (301) 443-1124; http://www.nida.nih.gov.
· National Institute on Alcohol Abuse and Alcoholism, (301) 443-3860; http://www.niaaa.nih.gov.
For information on smoking and stop-smoking programs, contact your local chapter of the American Lung Association.]
Reference
1. Trinkoff AM, Storr CL. Substance use among nurses: Differences between specialties. Am J Public Health 1998; 88:581-585.
Caceres VM, Kim DK, Bresee JS, et al. A viral gastroenteritis outbreak associated with person-to-person spread among hospital staff. Infect Control Hosp Epidemiol 1998; 19:162-167.
Small round-structured viruses (SRSVs) in the family Caliciviridae have been implicated in hospital gastroenteritis outbreaks. Known modes of spread include contaminated food or beverages and both direct and indirect person-to-person transmission. This study documents the role of person-to-person transmission primarily among staff during a hospital outbreak. The authors report an outbreak of acute gastroenteritis caused by SRSVs that probably were introduced by a health care worker at a South Carolina regional hospital, and they emphasize the importance of preventing staff from working while ill with gastroenteritis.
Nurse X was admitted to a medical-surgical ward A on Jan. 6, 1996, with dehydration, vomiting, and watery diarrhea. Nurse X usually worked on ward A, so was well-known to staff, who visited frequently during her hospitalization. On Jan. 7, two nurses who provided care to nurse X developed vomiting and diarrhea. A snowstorm that day prevented several ward staff from going home, so they shared sleeping quarters in the hospital. Subsequently, an outbreak of gastroenteritis occurred among staff and patients on ward A, and there were scattered reports of the illness in other parts of the hospital.
Control measures on ward A included strict adherence to enteric precautions (gowns, gloves, and facial masks), frequent hand washing, and sending home sick HCWs. Ward A was closed to new admissions on Jan. 12.
Investigators asked ward A staff to complete a questionnaire relating to infection control practices, food and water exposures, and other potential risk factors. Patient medical charts were reviewed for care received and potential risk factors. Case patients or families were interviewed to determine rates of illness among household contacts. The risk of contact between patient and primary care nurse was assessed. All hospital departments were surveyed to determine illness rates among employees during the first two weeks of January. Records of emergency department diagnoses were reviewed as an indicator of community incidence of acute gastroenteritis. Stool specimens from case staff and case patients were examined for viral particles, and the relatedness of detected SRSV strains was determined by reverse transcriptase-polymerase chain reaction.
During the study period, 89 staff worked on ward A caring for 91 patients. The attack rate was higher for staff than patients: 28 staff (31%) compared with 10 patients (11%).
No significantly increased risk of illness was associated with exposure to water, ice, or food; assisting in the care of colleagues' case patients; using the staff bathroom; or failure to use latex gloves. Staff who worked or stayed in the hospital longer than expected due to the snowstorm had greater risk of illness, although neither was statistically significant.
Investigators concluded that the probable source case was nurse X, who was hospitalized on ward A and visited by many staff colleagues.
"Evidence for person-to-person spread in this outbreak includes a characteristic epidemic curve, a high attack rate among primary patients and household contacts of case staff, and the absence of an epidemiologically implicated foodborne or waterborne source," the authors state. "The finding of an homologous strain of SRSV among patient and staff cases supports the hypothesis that the outbreak was propagated by the same virus."
As an alternative hypothesis for the source of illness, the researchers suggest an occupational or community exposure that first affected Ward A staff. In addition, a second SRSV strain, possibly community-acquired, was detected.
Unexpected illness transmission patterns on ward A were observed. The attack rate in staff was three times greater than in patients in contrast to other institutional gastrointestinal outbreaks. The investigators suggest this may be due to two case nurses who became ill at the hospital and were forced by the snowstorm to share sleeping quarters with other staff, and then continued to work through their next shift before going home. Several other staff worked while ill because of a staff shortage due to the weather conditions and illnesses.
The authors point out that "SRSV-associated gastroenteritis can spread rapidly among healthcare workers in the absence of substantial spread to patients." Even casual contact between staff can cause gastroenteritis outbreaks.
"Staff should not work while ill with gastroenteritis and, optimally, should not return to work until completely free of symptoms," they conclude.
1998 Frontline Healthcare Workers Safety Conference - Aug. 10-11, 1998, at the Washington, DC, Marriott Hotel. "Working Together in the Environment of Care" topics will include patient and worker safety in hospitals; HIV, HBV, HCV and postexposure prophylaxis; medical waste processing; FDA device regulation; latex allergies; and systematic failures in hospital epidemiology and surveillance. Registration fees are $95, earlybird; $195, advance; and $295, on-site. Contact the Frontline Healthcare Workers Safety Foundation Ltd. at (770) 399-3039.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content