Chemical dependency among nurses is one of the most critical problems facing the profession today. Almost 70% of the disciplinary cases heard by state boards of nursing involve substance abuse (Curtin, 1987). More than any clinical definition of addiction, the following would seem to sum up the devastating magnitude of chemical dependency in nursing:
When cocaine, alcohol, or narcotics come before the welfare of a beloved family member, a valued career, one's life savings, one's health, even the ability to avoid jail, that is addiction (Sullivan, Bissell & Williams, 1988, p. 4).
Nursing literature places the number of chemically dependent nurses anywhere between 6% and 20% of the profession's total membership (Creighton, 1988; Fiesta, 1990; Gelfand, Long, McGiIl & Sheerin, 1990; Trinkoff, Eaton & Anthony, 1991). This difficulty in accurately pinpointing the actual number of impaired nurses is an indication of the lack of education, understanding, and appropriate intervention strategies in dealing with the problem. While studies have shown that education, early intervention, and positive attitudes can improve the outcome for chemically dependent nurses as well as their employing institutions (Eller & Irwin, 1989; LaGodna & Hendrix, 1989; Robbins, 1987), the problem is still frequently dealt with in silence, with negative feelings and punitive actions (Hughes & Sullivan, 1989; Lippman, 1992).
The purpose of this study was to measure the perceptions and attitudes of nursing students toward chemically dependent nurses, and to determine the students' feelings about the importance and adequacy of content in their nursing education related to chemical dependency among nurses. The objective in presenting the Perceptions of Nursing Impairment Inventory (Nurses Assisting Nurses Project, University of Kentucky College of Nursing, 1987) to nursing students was to promote recognition of the subjects' personal attitudes and prejudices regarding impaired nurses. In the long term, employing institutions may benefit in hiring the new graduate who is knowledgeable about chemical dependency in the profession, has formulated positive attitudes toward recovery from the disease, and is interested in pursuing continuing education programs on the problem.
The problem of chemical dependency in nursing impacts on all areas of the profession. The financial impact is a great concern for employing institutions. Sullivan (1986) reported turnover costs, absenteeism, tardiness, incidents, accidents, errors, low staff morale and decreased productivity as some of the financially draining aspects of the problem. A detailed study conducted by LaGodna and Hendrix (1989) estimated that the cost to the nurse, the employing agency, and the State Board of Nursing in any given instance of late recognized chemical impairment exceeds $50,000. They suggest that cost-cutting strategies be aimed at early recognition and intervention programs.
Nursing management is frequently confronted with the problem of impaired practitioners. Hendrix, Sabritt, McDaniel and Field (1987) conducted a survey of 1,047 registered nurses on their attitudes and perceptions toward impaired colleagues, and reported that supervisors were significantly less likely than staff nurses to believe in the efficacy of treatment for impaired nurses. In addition, younger nurses were more likely than older ones to feel positive attitudes toward helping chemically dependent colleagues within the profession. Smith (1992) conducted the same survey with nurse managers and assistant nurse managers, and reported that, though both groups were generally supportive of the impaired nurse, there were indications that they may not fully comprehend the prevalence of the problem and may have difficulty recognizing early impairment. Cannon and Brown ( 1988) reported that less favorable attitudes toward impaired nurses were evidenced as the number of years of employment increased.
Nurse educators bear a responsibility for preparing students to deal with the serious problem of chemical dependency in nursing. There exists an urgent need for improved educational programs on chemical dependency in schools of nursing (Murphy, 1989). Hutchinson (1986; 1987) concluded that many nurses who become chemically dependent were originally attempting to relieve physical or psychological pain, often related to job stress, through self-medication. In a study of 300 recovering nurses, Sullivan, Bissell and Leffler (1990) reported disturbing new trends; that the addiction process was often starting earlier, sometimes even prior to nursing school, and that younger nurses were more likely to use narcotics, resulting in serious job performance problems. Hoffman and Heinemann (1987) found in a survey of 336 schools of nursing that only one to five hours of general content in chemical dependency were offered, regardless of the length of the program. Likewise, Murphy (1991) determined that the academic preparation of graduate nurses in substance abuse was far less than that determined necessary for dealing with the problem in clinical practice and leadership roles.
While some studies have been conducted with RN students in BSN programs (Hyman, et al., 1991; Spencer-Strachan, 1990), there exists a dearth of information regarding the attitudes of basic students toward chemical dependency within the profession. EJetermining the attitudes and perceptions toward impaired nurses with which nursing students enter the profession seemed a logical starting point for further research into effective forms of educational intervention and prevention. This study was designed to expand the knowledge base available to nurse educators regarding chemical dependency in nursing.
Instrument - Data were collected using the Perceptions of Nursing Impairmeni Inventory (PNH). This instrument was developed by the Nurses Assisting Nurses Project of the University of Kentucky College of Nursing (Hendrix, Sabritt, McDaniel, & Field, 1987). The 32 items on this Likert-type inventory offered four options, ranging from strongly agree to strongly disagree. This selfadministered tool was intended to measure the perceptions and attitudes of respondents toward chemical dependency in nursing colleagues. A Cronbach alpha reliability coefficient of .82 was reported (Hendrix, Sabritt, McDaniel, & Field, 1987). Permission was received from the authors to use the instrument, and to adapt it for student nurses. Three statements developed by the researcher related to the nursing education aspect of chemical dependency were substituted for three items on the PNII. The newly developed items were reviewed by nurse educators to establish face validity. The adapted tool and study were submitted to the Institutional Review Board (IRB) of the university where the study was conducted, and approval was granted.
Sample - A convenience sample was utilized for this exploratory pilot consisting of 79 junior baccalaureate nursing students attending an urban midwestem university. The subjects were chosen because they had no previous professional nursing experience, but had enough clinical experience to appreciate the impact of impaired practice. Contact was made in a self-contained classroom setting. Descriptive statistics of the sample indicated that the subjects ranged in age from 19 to 41 years, with a mean age of 25.6 years and a standard deviation (SD) of 6.29. The gender demographic revealed that 68 (87%) of the respondents were female, and 10 (13%) were male. Ethnically, 62 (81%) were White, 10 (13%) African-American, 3 (4%) Hispanic, and 2 (2%) Asian. Of the 79 participants, 47 (61%) reported previous close contact with a chemically impaired relative, friend or colleague.
Procedure - Questionnaire packets were distributed to the sample subjects during a regular class session. A cover letter explained the purpose of the study, established its voluntary nature, and assured the students' anonymity in responding. Each questionnaire defined impairment in relation to drug and/or alcohol abuse, and provided directions for completion. In addition, a brief request for personal background asked for age, gender, ethnicity, and previous history of close contact with a chemically dependent person. Finally, a separate sheet was distributed requesting the name and address of the students who agreed to be contacted in 3 to 4 years for a proposed longitudinal follow-up study. These sheets were returned and stored separately from the completed questionnaires.
Data were analyzed using the Statistical Package for the Social Sciences (SPSSX), with lower scores representing more positive attitudes toward impaired nurses. Scores were reported from 50 to 79, within a possible range of 32 to 128. The mean score was 67 (SD 6.20). A Cronbach alpha reliability coefficient for the tool used in this pilot study was reported at .70.
Subjects expressed generally favorable attitudes toward the treatability of impaired nurses, with 92% (n=73) in agreement that recovering nurses could again be productive and trustworthy following treatment. Most of the respondents viewed chemical dependency as an illness. However, 25% (n=20), including 6 of the 10 male subjects, still felt that impairment was evidence of a personality weakness in the affected nurse.
With a mean age of 25.6 years, this study reflected the attitudes of a younger population than accessed in any previous studies. Respondents agreed strongly with statements related to the State Board of Nursing's responsibility for providing referral to sources of assistance for impaired nurses, for funding research on prevention and treatment, and for providing impaired nurses with specific information regarding their legal and due process rights. While most of the subjects felt strongly that nursing supervisors were responsible for helping impaired nurses receive assistance, fewer respondents believed that co-workers shared in that responsibility. Less than one-half (n=30) of the subjects felt that they could recognize impaired nurses by their behaviors. Though most felt that support groups consisting of other impaired nurses could help, many subjects doubted that colleagues could help an impaired co-worker into recovery.
The respondents in this study expressed a strong disciplinary orientation to the problem of impairment. Almost one-third (n=23) felt that impaired nursing students should be dismissed from their educational program, and the majority of subjects felt strongly that recovering nurses should not be allowed to work in the profession until successful completion of a treatment program.
While 61% (n=47) of the group reported previous close contact with an impaired colleague, friend or relative, most of the respondents did not feel that impairment was a widespread problem in nursing. Education was reported as the most effective tool for prevention and intervention in chemical dependency by most of the eubjects. In addition, 92% (n=72) of the respondents felt strongly that their basic nursing program did not provide adequate content related to chemical dependency in the profession of nursing.
The purpose of this study was to measure the attitudes and perceptions of nursing studente toward chemically impaired nurses, and to determine the respondents' feelings related to the adequacy of their educational preparation for dealing with impairment. The subjects expressed generally favorable attitudes toward the treatability of impairment and the potential for recovering nurses to successfully regain full function within the profession. These data supported the findings of previous studies conducted by Cannon and Brown (1988), Hyman et al. (1991), and Smith (1992). Of interest were findings that revealed strong support in this youthful population for the responsibility of the nursing profession to assist the impaired practitioner. Data in this study supported those of Hendrix and colleagues (1987), who reported that "younger respondents [were] more likely to hold attitudes favorable to a responsibility to help within the profession" (p. 328). In denying that impairment was a widespread problem in nursing, the subjects exhibited an apparent lack of information on the statistical prevalence of impairment, as well as the profoundly negative effect the disease has on the profession.
Conclusions were not generalizable due to the convenience sampling procedure of this study. However, findings suggested the existence of a significant educational gap between the current content in nursing programs related to chemical dependency in the profession, and the actual knowledge and skills that students require in order to deal with the problem. This study has demonstrated that students enter the profession with positive attitudes toward the treatability of impaired nurses, and with a respect for the potential of education to combat the problem. Education, early intervention and positive attitudes have been shown to improve outcomes for the impaired nurse, the employing institution, and the nursing profession. Yet previous studies have demonstrated that favorable attitudes decline as the number of years in the profession increases.
Data from this study would seem to indicate that nursing education must support and capitalize on the generally positive attitudes of studente toward impairment, by providing improved and expanded programs related to chemical dependency in nursing. In bridging the existing educational gap with improved programs, positive attitudes may be sustained throughout the nurse's career. Nurse educators have the opportunity to provide students with the knowledge and skills required for active and proactive participation in the process of intervention and prevention of chemical dependency in the professional setting.
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