This article presents the need for chemical abuse education and rehabilitation options in schools of nursing. The literature reveals that nurses and students of nursing are both high-risk populations, but there is a paucity of information, specifically about chemical dependency among nursing students. This article describes one nursing school's response to chemically dependent nursing students. It took the form of developing a policy for dealing with these students; the process is discussed. The steps involved in developing this policy included four main aspects: education of faculty and students; assessing other policies; dialogue with the state regarding its diversion program; and writing a policy. Finally two specific case studies are cited to demonstrate policy application.
Overview of the Literature
Chemical abuse is prevalent among college students and health professionals, with nursing students also being vulnerable. This article describes our School of Nursing's response to the problem of chemical dependency among nursing students.
The Professional Nurses Quarterly ( 1986 ) labeled substance abuse "a major public health problem for the nursing profession." The incidence of chemical dependency in nurses is reported to be nearly two in every ten nurses (Kirkwood, 1985). Jefferson & Ensor ( 1982 ) state, "A significant factor contributing to the use of drugs by nurses is the easy access to pills, prescriptions, and narcotics.
Attitudes regarding the acceptability of self-medication and the 'impossibility' of nurses who 'know better' becoming addicted also contribute to the problem" (Jefferson & Ensor, 1982).
Nurses must seek to effectively help their impaired colleagues. Several factors are necessary to understand and work with nurse abusers: knowledge of drugs most commonly abused, detecting clues to drug abuse among nurses, and confronting suspected or known nurse drug abusers (Elaine B., Clare M., June S., & Janet A., 1974).
We need to learn to recognize symptoms of drug use. Jefferson & Ensor (1982) identifies changes in job performance that should be noted and documented, such as absenteeism, illogical charting, excessive errors, and minimum work load performance.
Many impaired nurses lack knowledge about chemical dependency. Jaffe (1982) found that alcoholic nurses felt being a nurse hindered the recognition and acceptance of their disease and that there was a lack of knowledge among their colleagues about alcoholism. Irwin (1988) found that 92% of nurses disciplined by the State of California stated their nursing education inadequately covered chemical dependency. Kelley (1985) found that the majority of nurses in her study lacked knowledge to formulate positive coping skills, were not educated in the disease of chemical dependency in nursing school, and experienced many re-entry problems and conflicts.
Another population at risk for chemical ' dependency is students. Ryser (1983) conducted a study of students and chemical abuse. A comparison of 1974 and 1980 data showed a significant increase in abuse of alcohol, methaqualone, and marijuana. Fifty percent of the students who used the Emergency Room for treatment came because the drugs were used to commit suicide or were a suicide gesture (Ryser, 1983).
Sheverbush & Kerle (1985) surveyed nursing faculty to determine how they handled students suspected of substance abuse. Most of these educators were reluctant to refer students for professional treatment because of the "friend, counselor, instructor complex" (Sheverbush & Kerle, 1985). Beyond this, few studies exist on chemical abuse among student nurses.
Developing a Response to Our Students
As some of our faculty confronted their own denial systems and became aware of the vulnerability of students to substance abuse, our school identified a need for a plan to intervene effectively with impaired students. The plan incorporated four main aspects: education of faculty and students; assessing other policies; dialogue with the state regarding its diversion program; and developing our own policy.
Education of faculty and students - First we as faculty needed to be more knowledgeable regarding chemical dependency. We conducted an all day workshop utilizing specialists in chemical dependency treatment. The workshop defined drug abuse and alcoholism, identified behavioral symptoms and clues associated with chemical dependency, described appropriate methods of intervention to assist individals in getting treatment, and compared various treatment programs.
We examined what students are taught about alcoholism and drug abuse. We already had two sections in the curriculum addressing the disease of chemical dependency; however we had not addressed the prevalency of the problem in the nursing profession. One step toward remedying this was to have a representative from the California State Board of Nurses Division Program come and address the issue at a student assembly.
Assessing other policies - Second, we assessed other organizations' chemical dependency policies. Ensor, Dilday, Harakel, Heins & Bowman (1982) shared the specific steps which their states have implemented to respond to chemically dependent nurses. Each of the response plans include contacting the impaired nurse to present objective data suggesting she was impaired, presenting treatment options, and informing her of the consequences of refusing treatment. We reviewed employee assistance programs, policies from other schools of nursing, and literature. The employee assistance programs took the position that employees who acknowledged a problem of chemical dependency would not lose their positions provided they accepted treatment. One school of nursing policy stated that an impaired student should be referred for professional counseling and complete an approved rehabilitation program prior to returning to full student status.
Dialogue with State Diversion Program - Third, we established a close working relationship with the nurses in the California State Board of Nurses Diversion Program. They provided excellent consultation, assisting us in educating our faculty and in evaluating individual student situations.
Developing a Policy - Fourth, we utilized what we had learned to formulate our own chemical dependency policy for students. The initial draft of this policy was written by two faculty, and presented to the School of Nursing Executive Council, and further revised.
Because of the university's traditional commitment to total abstinence, conflict arose as we attempted to reconcile that philosophy with a more redemptive approach. Some faculty questioned the disease concept of chemical dependency, viewing it as a moral problem with dismissal and punishment as the appropriate immediate response. Considerable re-education and persuasion were required before approval of the policy took place.
The policy next was presented to the School of Nursing Faculty Council where it was approved. According to this policy, faculty members who suspect a substance abuse problem will initiate two actions: first, they will document all objective data suggestive of the problem and remove the student from the setting if they are too impaired to function safely. Second, the student will meet with the faculty member, Dean/Associate Dean, and an expert in the area of substance abuse to discuss behavior and be presented with two options.
If the student recognizes and admits the problem and accepts the offer of assistance, he/she will be suspended while an appropriate treatment/counseling program is initiated, as detailed in a signed Memorandum of Agreement. Later the student's case will be reviewed by a committee of four for possible reinstatement after the student and treatment professionals indicate readiness for continuing school. A new Memorandum of Agreement will be signed.
The second option is dismissal from the program for students who refuse to admit the problem and accept treatment and rehabilitation.
How Our Policy has Been Used
Two situations have allowed us to assess handling chemically dependent students. The first situation occurred prior to approval of the policy. However, although a Memorandum of Agreement was not available, the alternatives presented were consistent with our current policy.
The first student did not seek help voluntarily. She had been displaying irritable and unpredictable behavior as well as increasing inability to complete her clinical assignments. One of the faculty went to this student's dormitory room after several of her classmates expressed alarm because of suicidal statements made by her. They were concerned because she was using "speed," marijuana, and other drugs.
Immediately upon entering the student's room the faculty member was aware of a strong smell of emesis pervading the room. She also noticed Dilaudid on the student's bedside table and multiple infected needle marks on her arm. When the instructor said she was there to help, the student replied, "I'm in pain, but I like my pain, and I don't want anyone to take my likes away from me."
That same day, in a meeting with the Dean of the School of Nursing, concern was expressed for the student's welfare. She was given the option of accepting treatment or being dismissed from the program. Angry and tearful, she refused to accept treatment. She was encouraged to weigh her alternatives for a few days for reconsideration. Continuing to refuse treatment, she was dropped from the program.
About a month later she entered treatment and now appears to be recovering. She is working and believes she'll be ready to complete her nursing degree soon.
The second situation involved an alcoholic nursing student. This student was not suspected of being impaired, although faculty had noted behavior changes. The student herself confronted the problem by revealing it to a faculty member. She entered the office, closed the door and said, "I'm an alcoholic and the bottle is bigger than I am." She explained she had participated in an outpatient program in her home state during the summer, but now that she was back in school she did not have this support.
The instructor informed her that as much confidentiality as possible would be maintained, but the Dean of the School of Nursing would have to be informed. She reluctantly agreed, saying, "Do what you must." The instructor documented the dialogue and sent a letter to the Dean informing her of the encounter. She then arranged an appointment with the Dean, the student, and herself. The options discussed were suspension from clinical nursing classes and entering treatment, or dismissal from the program. When the Memorandum of Agreement was presented, the student balked at signing it. She was given several days to think about it, after which another meeting was held, and the student willingly signed it. Her treatment included attending Alcoholics Anonymous meetings, a nurses' support group, and counseling with a clinical psychologist specializing in chemical dependency.
She withdrew from clinical nursing courses and was told that she would be considered for reinstatement only if she maintained sobriety and was making satisfactory progress in treatment. Since she wanted to complete her nursing course, she asked to be reinstated. A committee met to discuss her case and a second individualized agreement was drawn up which she signed prior to beginning clinical course work.
Initially her course of recovery was an uphill battle, but she managed to abstain with support. Now she reports she is starting to enjoy sobriety. Recently she worked with several of her classmates in giving a presentation on chemical dependency in the nursing profession. She is beginning to share new problems openly in Alcoholic Anonymous meetings, in her nurse's support group, and among classmates.
In retrospect, the second situation may have proved successful because the approved form of the policy and the Memorandum of Agreement were available for implementation. This enabled us to monitor the student's program and allowed us to reinstate her at the earliest possible date.
Our school has recognized a need to intervene more effectively with our impaired nursing students. The policy that was developed in response to this needed required time and patience and involved four main steps. These steps were: education of faculty and students; assessing other policies; dialogue with the state regarding its diversion program; and developing a policy of our own. We believe the policy has been helpful in intervening with impaired .students and we continue to evaluate and revise it. We challenge other schools of nursing and fellow nursing faculty to address this critical need in nursing education.
- Kirkwood, K. R. (1985). Addicted nurses: Clues to the hidden problem. RN. 48, 16-21.
- Jefferson, L. V, & Ensor, B. E. (1982, April). Help for the helper: Confronting a chemically impaired colleague. Am J Nurs, 82(4), 574-577.
- Elaine B., Clare M., June S., & Janet A. (1974, September). Helping the nurse who misuses drugs. Am J Nurs 74(9), 1665-1671.
- Irwin, B. (1988). The process of recovery of chemically dependent nurses in California. Unpublished manuscript.
- Jaffe, S. (1982, April). Help for the helper: Firsthand views of recovery. Am J Nurs 82(4), 578-579.
- Kelley. R.D. (1985. July/August). The fate of recovered chemically-dependent. Michigan Board of Nursing disciplined RN's. The Michigan Nurse, 58(4), 8-10.
- Ryser, R E. (1983, September). Students and drug abuse, 1974 and 1980. Journal of School Health, 53(7), 435-436.
- Sheverbush, J. & Kerle, D. (1985, April). Pre-professional and substance abuse: How are nursing educators handling the problem? Kansas Nurse, 60(4), 16.
- Ensor, BE., Dilday, RC, Harakel, B.M., Heins, M., & Bowman, R. A (1982, April). Help for the helper: What the SNA's are doing. Am J Nurs, 82(4), 581-584.
- The Professional Nurse's Quarterly. (1986). Substance abuse: A major public health problem for the nursing profession. 1,1.