Substance abuse disorders are a major problem in nursing. Substance abuse disorders lead to more deaths, disabilities and illnesses than any other preventable health condition (NIDA, 2007). While abuse affects up to 15 percent of nurses, it may be partly beyond the nurse’s control, genetic factors account for 40-60 percent of an individual’s susceptibility to addiction (NIDA, 2008).
Substance abuse contributes to missing work, injuries, reduced productivity, liability, societal harm, person harms and increased health care costs. It is beneficial, not only for the employee, but also the employer to assist their workers in managing alcohol and substance abuse.
Nurses lack education regarding the addiction process, how to identify those with addiction and how to implement effective interventions. It is important that nurses receive education about substance use disorders. Employers can have significant impact in improving the nurse’s knowledge and attitude toward substance abuse.
Employers should implement strategies to promote safety and provide assistance. Guidelines should be developed to promote safety for nurses and their patients and offer assistance to nurses who suffer with substance abuse or other conditions that lead to impairment.
Policy should be a drug free work place and having all nurses fit to practice. Practices that will reduce the risk of impaired nurses on the worksite include: pre-employment drug testing, for cause testing (testing when there is logical suspicion that the employee is under the influence of drugs while working) and fitness to practice evaluations.
The workplace should promote a culture of transparency and consist of clear expectations and consequences. In addition, it should be clear that there is openness to help the nurse with a substance abuse problem or other condition that leads to impairment.
The workplace has significant potential to identify and help workers with drug and alcohol problems. Workers spend a lot of time at work and co-workers and supervisors may be able to notice signs or symptoms of drug or alcohol problems and assist them in getting the help they need.
Employers may influence employees to get help for impairment. Many employers have employee assistance programs (EAP) and/or educational program to help prevent drug or alcohol problems or other causes of impairment. Programs may include health promotion, education, and referral to alcohol and other drug abuse treatment if needed. These programs look to quickly identify problems and intervene early.
Drug or alcohol problems are often identified in the workplace when there is a poor-quality of work, attendance problems, when an employee self-refers to an EAP or when a co-worker identifies a drug or alcohol problem in another worker (Roman & Blum, 2002).
The primary goal of an EAP is to help employees maintain their job and career. While these programs are not free and may cost the employer significant money, research suggests that EAP provide more savings than it costs. The U.S. Department of Labor reports that 5 to16 dollars are saved for every dollar spent in an EAP. This is done through a 75% reduction in inpatient substance abuse and alcohol treatment programs; a 65% reduction in accidents occurring on the worksite; a 66% reduction in absenteeism related to alcohol abuse and a 30% reduction in workers compensation claims (Preferred Employee Assistance Program & Behavioral Health Services, 2010).
While it is not illegal to drink alcohol, the effect of drinking off the job can effect on the job performance. For example, binge drinking may lead to hangovers the next day which may compromise work performance. Employers do have a reason to attempt to modify employee drinking as this may positively affect work performance. Hangovers increase the risk of bad judgment, injuries, impair motor or cognitive function and reduce work productivity (Roman & Blum, 2002).
The ideal way to address off the job drinking is through alcohol education programs at work through EAP or another health promotion program with the goal of encouraging behavioral change. This may even encourage the patient who is impaired to self-refer themselves to treatment programs.
Alcohol education programs also have the potential to teach workers to identify an impaired co-worker. A nurse who works alongside another nurse is more likely to identify problem behaviors before a supervisor notices the same problem behaviors.
Health promotion programs are often put on by employers to help motive their employees to change behaviors. Drinking and drug use can affect health; teaching employees about healthy alternatives has the potential to change behaviors. For example, engaging in exercise, adapting a healthy diet or taking up a stress management program may reduce drug or alcohol use.
Risk factors in the work environment for alcohol and drug use include: stress, alienation and a culture of drinking within an organization (Roman & Blum, 2002). Chronic work stress, a large number of hours worked, unhealthy work conditions and poor workplace safety is linked to alcohol related problems (International Center for Alcohol Policies, 2015). The employer has a responsibility to determine if risk factors are present within the work environment and attempt to modify the work environment to reduce the risk of alcohol and drug use.
Addressing alcohol and drug use in the work setting has many similarities to addressing it in primary care. Both the worksite and the primary care office have significant preventative potential. Much variability exists between the content and quality of interventions between health care settings and places of employment. Unfortunately, there is the potential to hide problem behaviors and unless the health care provider or the worksite finds a problem no intervention will occur. Both the primary care setting and worksite have many roles to fulfill and preventing, identifying and treating substance and alcohol abuse is not the highest priority goal in either setting.
Employers may resist intervention in prevention programs for multiple reasons including (Roman & Blum, 2002):
- Concern that reducing alcohol problems will be costly and only benefit the individual and not the employer
- A concern that prevention programs may suggest the employer is contributing to drug and alcohol abuse
- Concern that those treating alcohol or drug use will not have the workplace’s best interest in mind and will be unreasonable, costly and impede work productivity.
EAP assist substance abuse programs within companies. It is estimated of worksites with over 100 employees, 66% have EAP programs and ninety percent of Fortune 500 firms have a similar program (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007). EAP programs are not solely derived to address substance abuse, they also help employees with other issues such as mental health, marital problems, parenting problems, financial problems, legal issues and balancing life and work. They offer visits to provide assessment or short-term counseling. Employees may be referred to an outside provider for follow up treatment.
Employees may not get involved in EAP for a variety of reasons. Employees often do not feel that their problems will be held confidential, but they are confidential. Many employees may also feel shameful for looking for help. Some employees fear that they need to get permission from their boss, but they can self-refer to an EAP. Lastly, many do not know that they exist.
When looking at EAP outcomes, the majority of studies suggest that they provide positive economic benefits and improved work and clinical outcomes (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007).
Some workplaces more strongly promote EAP than other workplaces. Factors that contribute to enhanced use of EAP include: employee awareness, supervisor training, belief in EAP, willingness to use EAP and when EAP are promoted optimistically in company policy (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007).
Individuals who use a company EAP are more likely to take part in and stay engaged in alcohol and other drug treatment programs. Factors associated with greater use of EAP include: major depression, black race/ethnicity, or any drug use disorder (Jacobson & Sacco, 2012).
Determining impairment from mental illness is a tricky task. A scale, the Nurses Work Functioning Questionnaire, has been developed to determine if there is impairment from common mental illnesses. It is a 50 question survey that has been determined to be highly reliable and valid. The survey includes seven subscales that predict the exact aspect of impairment and helps in determining interventions to help the impaired nurse (Gartner, Nieuwenhuijsen, van Dijk, & Sluiter, 2011).