preceptions chemically impaired nursing

REGISTERED NURSES’ PERCEPTIONS OF WORKING WITH CHEMICALLY

IMPAIRED REGISTERED NURSE COLLEAGUES

by

Kimberly S. Esquibel

REBA GLIDEWELL, Ph.D., Faculty Mentor and Chair

SHARLENE ADAMS, PsyD, Committee Member

BEVERLY GOODWIN, Ph.D., Committee Member

Deborah Bushway, Ph.D., Dean, Harold Abel School of Psychology

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Capella University

July 2009

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UMI Number: 3360070

Copyright 2009 by Esquibel, Kimberly S.

All rights reserved

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© Kimberly S. Esquibel, 2009

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Abstract

Although many studies have been conducted to learn more about the experiences

of chemically impaired nurses, few studies have attempted to describe the experiences

and perceptions of nurses who work with impaired colleagues as a discreet population.

Guided by King’s (1981, 1996) theoretical framework, this qualitative, phenomenological

study explored the perceptions of 12 registered nurses working with a chemically

impaired registered nurse colleague as a personal lived experience. Each member of the

purposefully selected sample participated in an audio-taped, open-ended interview with

the researcher. The interviews followed a guide developed by the researcher. The data

was analyzed according to Colaizzi’s (1978) procedural steps. Five major themes

emerged which were centered on the influence of personal values, professional impact, a

culture of silence and denial, lack of education, and a professional stigma and

stereotypical views. The findings of the study reflect the overall need for educating

nurses about the addictive disease process, workplace policies on addiction and

treatment, peer assistance programs including personnel with knowledge of addictions,

training in interventions, and awareness of referral options and availability of resources to

help support nurses’ recovery from addictions. This study will add to the current body of

the professional literature. Also, the previous lack of scholarly exploration in the area of

colleagues who work with impaired nurses may propagate future qualitative inquiry.

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Dedication

This dissertation is dedicated to the many nurses who struggle with chemical impairment

and to the colleagues who struggle to help them. I extend my prayers to all of you who

seek freedom from chemical impairment and to those who can help you to reach that

goal. I wish you Godspeed.

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Acknowledgments

I extend warmest appreciation and respect to Dr. Reba Glidewell, my Capella

mentor and committee chair. Her calm, enthusiastic support and unyielding guidance

encouraged me throughout my Capella dissertation process. Her commitment to and faith

in both this study and me inspired the ideas, energy, and perspective that went into this

dissertation project. It has been an honor and privilege to work with you. I would also

like to thank Dr. Sharlene Adams and Dr. Beverly Goodwin for their work as instructors

and willingness to be on my dissertation committee.

I wish to extend my deepest thanks to the research participants who so generously

gave of their time to share their personal stories and experiences. I am eternally grateful

for your candor and courage to speak of your experiences, and thank you for providing

me with the rich experience of sharing your stories. Your stories truly made my study

come to life.

I would also like to thank those closest to me. To my mom who has been a source

of light and encouragement, teaching me perseverance and patience throughout my life;

my dad who taught me about setting goals and creating opportunities; and my brothers,

who have taught me about seeing the lighter side of life and remembering to laugh. To

John who has been by my side throughout my journey. I thank you for your endless

encouragement, love, and teaching me to believe in myself. To my canine friends, Max

and Scooter, you spent countless hours lying at my feet while I worked at the computer.

And finally, I wish to thank my son Brendon who is the greatest source of joy in

my life. You have provided me with the encouragement to complete my Ph.D. You are

my source of strength and I love you more than words can say.

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Table of Contents

Acknowledgments iv

List of Tables viii

CHAPTER 1: INTRODUCTION 1

Introduction to the Problem 1

Background of the Study 3

Statement of the Problem 4

Purpose of the Study 6

Rationale 7

Research Questions 7

Significance of the Study 9

Definition of Terms 10

Assumptions 13

Limitations 14

Nature of the Study 15

Theoretical/Conceptual Framework 16

Organization of the Remainder of the Study 22

CHAPTER 2: LITERATURE REVIEW 24

Chemical Misuse and Impairment in Nursing 24

Recognizing Signs of Chemical Impairment 29

Recognizing Signs of Drug Diversion 31

Obstacles to Identification and Early Reporting of Chemically Impaired Nurses 32

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Reporting Behaviors of Colleagues 41

Attitudes toward Impaired Nurse Colleagues 44

Legal and Ethical Considerations of Impaired Nurse Practice 47

Application of King’s Theory of Goal Attainment Within this Study 49

Summary 50

CHAPTER 3: METHODOLOGY 52

Purpose of the Study 52

Research Design 53

Methods 55

Procedures 59

Expected Findings 78

CHAPTER 4: DATA COLLECTION AND ANALYSIS 81

Introduction 81

Description of the Sample 82

Research Methodology Applied to the Data Analysis 84

Presentation of Data and Results of Analysis 85

Research Question 1 86






Presentation of Major Themes in Data Analysis 139

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Essence 150

Validity and Reliability 151

Summary 151

CHAPTER 5: RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 153

Introduction 153

Summary of the Results 153

Discussion of the Results 155

Discussion of the Conclusions 170

Limitations to the Study 181

Implications for the Field of Psychology and Nursing 182

Recommendations for Further Research 185

Conclusion 186

REFERENCES 188

APPENDIX A: PARTICIPANT DEMOGRAPHIC HISTORY FORM 199 APPENDIX B: INTERVIEW QUESTIONS 202

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List of Tables

Table 1: Correlation of Sub-themes Highlighting the Perceptions of the Participants with King’s (1996) Concepts within the Personal System 162 Table 2: Correlation of Sub-themes Highlighting the Perceptions of the Participants with King’s (1996) Concepts within the Interpersonal System 165 Table 3: Correlation of Sub-themes Highlighting the Perceptions of the Participants with King’s (1996) Concepts within the Social System 168

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CHAPTER 1: INTRODUCTION

Introduction to the Problem

The problem of chemical abuse and dependency crosses all boundaries, including

gender, race, culture, age, and class (Sheehan, 1992). Abuse of chemical substances,

either alcohol and/or other mood altering drugs, is a major health problem that negatively

affects the lives of millions of Americans. Nearly 20 million adults in the United States

are problem drinkers, and 14 million of them suffer from alcoholism (National Institute

on Alcohol Abuse and Alcoholism, 2000). An additional four million individuals are

believed to be drug abusers. Two million of these individuals are considered to be non-

narcotic drug abusers and three million are considered to be narcotic drug abusers

(National Institute on Drug Abuse, 1999).

The workplace is not immune to chemical abuse and dependency problems.

Studies show that at least 1 of every 10 American workers use illegal drugs on the job

(Brice, 1990; Galvin, 2000). Any job performed in an impaired condition constitutes

some risk or loss to society (Galvin, 2000; Sullivan, Bissell, & Williams, 1988).

The problem is even more significant in the health care professions. Coombs

(1997) found that drug abuse is at least as prevalent among highly regarded professionals

(physicians and other health care professionals) as among the general public. McAuliffe

et al. (1986) reported that 59% of physicians had used psychoactive drugs in their lives;

while one in four had abused prescription drugs and one in ten were projected to use

drugs regularly during their career. By the middle of the 1990s, over 60,000 registered

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nurses were thought to be alcoholic and somewhere between two and four percent were

thought to be addicted to drugs (Trinkoff & Storr, 1998). Today, eight to 10 percent of

the 2.2 million registered nurses in the United States are estimated to have chemical

addiction problems (Copp, 2009; Snow & Hughes, 2003; Stammer, 2007).

Despite their professional education, nurses are not immune to chemical

dependency. Often the disease is severe by the time their work is affected (Fink,

Hickman, & Miller, 1993; Quinlan, 2003). Nurses, who practice while impaired, place

their patients, colleagues, themselves, and the entire health care community at risk. The

threat to patient welfare posed by impaired nursing through substandard care and possible

diversion of medication is a matter of genuine concern (Snow & Tipton, 2006).

As a health care profession, nursing accepts the disease definition of addiction

and has made an effort to work toward its prevention and treatment, both among the

general population and within its own ranks (Naegle, 2003). Problems related to

substance abuse unfortunately often do not arise until the problem has reached a serious

level. Usually by the time a nurse is confronted with a substance abuse problem, most of

his or her colleagues were already aware of the problem but had not said anything about

it (Taylor, 2003).

One phenomenon that surfaces in the literature is a delay in occupational

reporting for substance abuse treatment (Gossop, Stephens, Duncan, Marshall, Bearn, &

Strang, 2001; Huton, 2005; Weiss, 2005). But while there is scholarly consensus that

delays exists minimal research has been conducted on the reasons for such delays; and no

one has studied the reasons that nurses delay or do not report chemically impaired nurse

colleagues. Thus, research is needed to determine why some nurses with substance abuse

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problems are not being adequately identified by their nurse colleagues and referred for

treatment in a timely fashion. Research in this area may assist nurse colleagues to more

efficiently identify chemical abuse and abusers to speed up the referral process.

Understanding registered nurses’ perceptions of working with chemically impaired

colleagues as a personal lived experience might help to illuminate how the process could

improve.

Background of the Study

The problem of nurses with substance-related disorders is not new. The problem

gained an increased awareness in the early 1980s when the American Nurses Association

(ANA) (1984) defined an impaired nurse as “one who, as the result of alcohol and drug

abuse, has difficulty functioning in the nurse role” (p. 18). This, in turn, interferes with

their ability to provide safe, effective care. The period of the late 1980s into the 1990s

saw the emergence of formal research on addiction and substance use in nursing with a

focus on risk factors, attitudes about, effects, and consequences of impairment. Little

attention has been given to early identification of chemically impaired nurses, early

reporting, and interventions to assist nurses to recognize impaired nurse colleagues. In the

last ten years research has focused on treatment and re-entry into practice.

A positive step was made in 1992 when the American Association of Colleges of

Nursing (AACN) created a Substance Abuse Task Force. The task force was charged

with developing a policy statement to address the problem of substance abuse in the

nursing community. The task force recognized that substance abuse is a universal health

problem that affects all segments of society and that substance abuse is a major issue for

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nursing students, faculty, and staff. The general assumptions and principles used by the

task force in developing policies and guidelines emphasized that substance abuse in

nursing education must be addressed, but most of the assumptions focused on risk

factors, monitoring of nurses with substance abuse problems, rehabilitation, and re-entry

into practice. Again, very little emphasis was given to early identification and reporting

of substance impaired nurses. In a position statement by the task force, only two

paragraphs addressed education and early identification (AACN, 1996). The majority of

the research literature found was published in the 1980s and late 1990s. Most studies

published in the last 8 years address the chemically dependent nurse.

Having worked with nurses, who practiced while impaired by chemical

substances, initially sparked my interest to learn more about this phenomenon. In

reviewing the literature it became increasingly evident that little attention has been given

to registered nurses’ perceptions of impaired nurse colleagues as a personal lived

experience. Specifically, why do some nurses report impaired colleagues and others do

not? What experiences do nurses go through in making the decision to report, not report,

or delay reporting a chemically impaired nurse colleague? Do nurses’ perceptions of their

colleagues affect their decision to report? Miller (1997) indicates that nurses themselves

are in the best position to identify changes or problems in their colleague’s nursing

practice.

Statement of the Problem

Chemical impairment in nurses is a prevalent and serious problem yet little has

been published that describes the actual perceptions of registered nurses toward

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chemically impaired nurse colleagues as a personal lived experience. Many qualitative

studies have been conducted in order to learn more about the experiences of the

chemically impaired nurse from a variety of perspectives. For example, studies have

described the experiences of nurses being labeled chemically impaired (Brewer & Nelms,

1998; Lillibridge, Cox, & Cross, 2002), described the experiences of recovering nurses’

re-entry to practice (Hughes, Smith, & Howard, 1998), and described attitudes and

perceptions of chemically impaired nurses’ experiences with chemical misuse (Shaffer,

1988; Tariman, 2007). In addition, Wennerstrom and Rooda (1996) studied attitudes and

perceptions of nursing students toward chemically impaired nurses while Smith (1992)

studied attitudes and perceptions of nurse managers and assistant nurse managers toward

chemically impaired colleagues. However, few, if any, studies have attempted to describe

registered nurses’ perceptions of impaired registered nurse colleagues as a personal lived

experience.

Fellow nurses of those with a substance abuse problem have an ethical and legal

obligation to report a colleague whose activities could result in harm to a patient.

Remaining silent about a colleague’s suspected problem violates a nurse’s ethical duty to

safe-guard patient care. According to the ANA (2003), nurses are responsible for

responding when a colleague is exhibiting questionable actions or practices by reporting

suspicions to the appropriate personnel as an advocate to the patient.

Another reason for reporting a colleague’s substance abuse, beyond patient

advocacy, is to help the nurse at risk. Reporting nurses with an addiction could save their

lives and help them to keep their profession after they obtain treatment. Friendship and

loyalty among the nursing community often makes it easier for colleagues to look the

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other way at suspicious behavior and deny that there is a problem (Smith, Taylor, &

Hughes, 1998).

In one study, 91% of respondents stated they would report an incident by an

impaired colleague that either harmed patients or put them at risk for harm. In actuality,

only about half that number reported incidents that they witnessed that possibly put a

patient at risk for harm (Taylor, 2003). It is also presumed that many nurses react

negatively to their peers who abuse substances (Brewer & Nelms, 1998; Burke, 1999;

Hendrix, Sabritt, McDaniel, & Field, 1987). Thus, nurses who become addicted might be

more likely to feel shame and experience guilt, which can also delay treatment and

recovery. The lack of collegial response, as well as insufficient education, may also play

a major role in the late identification of peers with addiction problems.

Purpose of the Study

The purpose of this study was to discover and interpret registered nurses’

perceptions of impaired nurse colleagues as a personal lived experience. The study used a

qualitative, phenomenological approach. Through a comprehensive analysis of

transcribed interviews, demographic sheets, and field notes, I was able to understand the

lives of the participants as related to their perceptions of working with impaired nurse

colleagues. Ultimately, the focus of this study was to identify the needs of registered

nurses who work with impaired nurse colleagues as related to early identification and

reporting.

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Rationale

Gaining insight into registered nurses’ perceptions toward impaired nurse

colleagues is crucial because many may not recognize chemically impaired colleagues

and may dismiss unusual or inappropriate behavior as simply responses to a temporary

crisis, problems at home, frustration with the job, fatigue, and physical problems that may

warrant medical treatment. These problems provide a rationale for a colleague’s changes

in behavior and job performance. The subtle signs of substance abuse may be dismissed

as nothing out of the ordinary. Furthermore, enabling behavior is common among the

colleagues of substance abusing nurses (Pullen & Green, 1997). Enabling occurs when a

harmfully involved person is protected from the full negative consequences of their use.

Although well intentioned, enabling behavior is a serious obstacle to dealing with the

problem of substance abuse. If nurses are unaware of what is going on, they may actually

enable impaired nurses with behaviors such as covering for them. By gaining an

understanding of registered nurses’ perceptions of impaired nurse colleagues, appropriate

education and earlier identification and reporting may result. The primary aim of this

study was to gain insight into registered nurses’ perceptions of working with impaired

nurse colleagues. The goal was to identify ways to improve the identification of and early

reporting of impaired practice.

Research Questions

In this study I attempted to describe registered nurses’ experiences of working

with impaired nurse colleagues and their perceptions toward these colleagues. Further, I

sought to determine whether their perceptions affected their experience. My previous

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readings and study on the subject of chemically impaired nurses, King’s (1996) theory of

goal attainment, along with the purpose of the study, were the primary guides in the

development of the guided questions participants were asked.

The qualitative nature of this study carried with it the underlying belief that a

single, ultimate truth did not exist (Guba & Lincoln, 1989). It was believed that multiple

perspectives of the same phenomena may be held by different participants, each having

comparatively equal authority (Leedy & Ormrod, 2005). As such, the following questions

guided the study:

1. What types of experiences have nurses encountered with a chemically impaired

colleague in the workplace?

2. How do nurses perceive colleagues who practiced while chemically impaired?

3. How did nurses react to their chemically impaired colleagues?

4. What factors in nurses’ personal system influenced their perceptions of and

reactions to their chemically impaired colleagues?

5. What factors in nurses’ interpersonal system influenced their perceptions of and

reactions to their chemically impaired colleagues?

6. What factors in nurses’ social system influenced their perceptions of and reactions

to their chemically impaired colleagues?

The research questions were related to the research problem as they were broad in

nature and allowed for a variety of themes to emerge from the responses given by

participants. The questions were also related to the major concept in this study, the

phenomenon of chemically impaired nurse colleagues from the perspective of registered

nurses who worked with them. Analysis of the data sought to answer these questions.

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Significance of the Study

This study is important to psychologists who work with nursing staff in hospitals,

to substance abuse therapists in general, and to the field of psychology as a whole. The

significance to the field of psychology includes an increased understanding of the

complexities of personal, interpersonal, and social systems as nurses perceive and

describe their experiences of working with impaired nurse colleagues. As a result, it may

provide valuable information for implementing substance abuse education, early

identification, and early reporting programs to assist nurses.

Although the literature describes the typical chemically impaired nurse (Bissell &

Jones, 1981; Bugle, 1996; Finke, Hickman, & Miller, 1993; Finke, Williams, & Stanley,

1996; Lillibridge, Cox, & Cross, 2002), and addresses areas of attitude, risk factors,

treatment, recovery, and re-entry into practice, the lived experience of nurse colleagues

has been neglected. Many of the above studies explore chemically impaired nurses’

views of their colleagues from a qualitative perspective; however, the voice of the

colleague has been neglected. Thus, exploring nurses’ descriptions of their experiences of

working with chemically impaired colleagues benefits the field of psychology by adding

to the existing knowledge base in terms of understanding the needs of nurses who work

with impaired nurse colleagues. It provides new knowledge on chemically impaired

nurses from a perspective other than that of the impaired nurse. Finally, the qualitative

nature of this study and previous lack of scholarly exploration in the area of nurses

working with impaired colleagues propagates future research possibilities for

psychologists in other population work groups.

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Definition of Terms

The key phenomenon under investigation in this study was registered nurses’

perceptions of the chemically impaired nurse colleague as it was experienced by the

participants. To aide the reader, the following terms were defined as they were used in

this study and as reflected in the research questions:

Chemically impaired. The diminished ability to function in a professional role due

to the use of chemical substances (Miller-Keane, 2002) as reflected by the participants’

perceptions that their nurse colleagues’ work abilities had diminished because of a

chemical substance.

Colleague. A registered nurse who was the co-worker of another registered nurse.

Encountered. To have come upon unexpectedly (Webster’s New World College

Dictionary, 2003) as reflected by the participants who, by chance, personally experienced

working with an impaired nurse colleague.

Experiences. The state of being affected by an event (Webster’s New World

College Dictionary, 2003) as reflected by past activities or events that affected

participants’ perceptions and reactions toward chemically impaired colleagues.

Factor. The “circumstance, condition, detail or element which has a bearing on an

outcome” (Webster’s New World College Dictionary, 2003, p. 57) as reflected by those

circumstances, conditions, details, or elements of the situation, which the participants

perceived influenced their perceptions of working with chemically impaired nurse

colleagues.

Impaired nurse. A nurse who “habitually or excessively” uses or is dependent on

alcohol, narcotics, stimulants, or any other chemical agent or drug that results in inability

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to practice with reasonable judgment, skill or safety. Implies working under the influence

of non-prescribed mood-altering substances (Griffith, 1999, p. 24) as reflected by the

participants’ descriptions of an impaired colleague.

Influenced. Having had a “change in the character, thought, or action of” (New

World Dictionary, 2004, p. 628) as reflected by participants’ discussions of the factors

which caused a change in their perceptions of chemically impaired colleagues as they

answered the interview questions.

Interpersonal system. The interaction with the environment of a smaller group

within a larger group (King, 1981). King (1992) identified the concepts of

communication, interaction, stress, role, and transaction to be significant factors within

the interpersonal system. The interpersonal system was reflected by the factors related to

the concepts within the interpersonal system that participants’ identified as they answered

the interview questions.

Lived experience. The term used in phenomenological studies to emphasize the

importance of individual experiences of people as conscious human beings (Moustakas,

1994) as reflected by the actual experiences of the participants as they described it in

their own words.

Perception. The process of organizing, interpreting, and transforming information

from sense data and memory; the process of human transactions with the environment. It

gives “meaning to one’s experience, represents one’s image of reality, and influences

one’s behavior” (King, 1981, p. 24). Perception was reflected by the feelings, thoughts,

emotions, and ideas expressed by the participants as they answered the interview

questions.

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Personal system. King (1981) identified the concepts of perception, growth and

development, body image, self, learning, and time and space to be significant within the

personal system. The personal system was reflected by the factors related to the concepts

within the personal system that the participants identified as they answered interview

questions.

React. To act in response to as reflected by the participants to have responded to a

situation in which a colleague was working while chemically impaired.

Reaction. A “return or opposing action or influence” (Webster’s New World

College Dictionary, 2003, p. 118) as reflected by the response(s) influenced by factors in

the personal, interpersonal, and/or social systems of participants toward their chemically

impaired colleagues they worked with.

Registered nurse. A person licensed by the state board of nursing to practice

professional nursing in a given state (Delaune, 1998) as reflected by the health care

professionals, who met the criteria for selection for the sample of this study, and the

chemically impaired colleagues the participants described with whom they worked.

Social system. The circumstance, condition, detail or element which has a bearing

on an outcome as reflected by the factors related to the concepts of authority, control,

decision-making, organization, status, and power (King, 1981) that the participants

identified as they answered the interview guide questions.

Workplace. An area where one performs job tasks as reflected by that which was

described by each participant as being the place where he/she worked with a chemically

impaired nurse colleague.

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Assumptions

A key function in the analysis of the data was bracketing preconceived notions

and suppositions about the phenomenon. By acknowledging and suspending personal

biases, then putting them aside, the “life world” of the participants was revealed (Husserl,

1970). According to King (1981), nursing’s focus is on individuals interacting with their

environment, which leads to a state of health for individuals allowing them to function in

social roles. The following assumptions, several for which are consistent with King’s

(1996) theory, were made for this study:

1. Some nurses have health problems related to addictions and consequently may

practice while chemically impaired.

2. Being under the influence of alcohol and/or other mood altering substances will

influence nurses’ ability to practice safely and effectively.

3. Nurses, who are dependent on alcohol and/or other mood altering substances, can

regain their health by pursuing recovery from addiction.

4. The nurses’ “goals, values, and needs will influence” (King, 1981, p. 143) their

experiences and perceptions of chemical misuse and their reactions to colleagues

who practice while impaired.

5. The experiences of nurses and perceptions of nurses toward their colleagues who

practiced while chemically impaired will have influenced their interactions with

these individuals.

Furthermore, it was assumed that participants would be truthful in the descriptions

of their experiences and able to respond to all interview questions and to any additional

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demographic questions. It was also assumed that the participants would have a desire to

share their stories.

Limitations

Limitations are conditions beyond the control of the researcher that might restrict

conclusions of the study and how they might be applied to other situations (Best & Kahn,

1993). Possible limitations of this study and areas that were believed could not be

improved despite being a weakness included: (a) the findings of this study cannot be

generalized to all registered nurses who have worked with chemically impaired nurse

colleagues; (b) the findings of this study cannot be generalized to other populations of

individuals who have worked with chemically impaired colleagues; and (c) the findings

of this study were restricted to the recall ability of the participants of the study as there

was certainly the potential for underreporting of experiences by participants. According

to Van Manen (1990), we must “remain aware that lived experience is always more

complex than any explication of meaning can reveal” (p. 18). Thus, in relying on the

participants’ ability to recall and describe their experiences, I could never truly know that

the experience of working with impaired nurse colleagues from the perspective of

registered nurses was fully captured. The sample was also purposive and not

representative of the population of registered nurses who have experienced the same

phenomena. Experiences and perceptions of participants were their own and may not be

the same as other nurses. Finally, my interview experience was limited to a pilot study.

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preceptions chemically impaired nursing

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