Posted: 1/8/2018 1:51:43 PM

The Signs of Substance Abuse in an Impaired Nurse

Diane, a mother of two, has been a nurse for eight years and has a consistently excellent record of performance at work. She seems to have it all together in both her work and family life. At home, she cares for her 5-year old son, who has Attention Deficit Hyperactivity Disorder (ADHD), and a toddler attending daycare. At night, she works in a nearby hospital. Coworkers and patients have high opinions of Diane, because she always has an energized “Hello!” for everyone, all the way until morning, when everyone else is feeling beat. She also looks underweight, and others speculate it is because she frequently skips her breaks.

Everyone was shocked when they learned that her RN license was revoked because she had been abusing Ritalin, a drug prescribed for her son, and which has similar effects to cocaine. Diane’s Ritalin abuse started out for a seemingly harmless reason, to keep her up when her then newborn was sick. However, her drug use spiraled out of control and she started looking for reasons to take the drug.

Substance abuse is a huge social problem, and it is present in healthcare as well as the general public. An estimated 10%-15% of all healthcare professionals abuse substances, such as drugs and alcohol, in their lifetime. According to the American Nurses Association, these numbers are also true for nurses, meaning that for every ten nurses, one of them is likely struggling with addiction.

Impaired nurses are a danger to themselves, their coworkers, and especially their patients. As an RN yourself, it is your duty to look after patients' safety at all times, so be wary of nurses who may be abusing drugs or alcohol. Remember that these nurses will do their best to conceal their addiction and appear normal, but there will usually be indications that give them away. Be alert for these physical signs of substance abuse:

1. Unsteady movement or gait
2. Tremors of the hands
3. Slurred speech
4. Pupil dilation or constriction
5. Sudden loss of consciousness
6. Rhinorrhea
7. The smell of alcohol, possibly disguised by breath mints

Nurses who abuse substances will also exhibit changes in behavior. Behavioral manifestations of substance addiction are usually observed earlier than the physical signs. Changes in behavior may include:

1. Frequent tardiness and absenteeism
2. Frequent bathroom breaks
3. Taking breaks alone, in isolation
4. Concealment of needlestick marks by wearing long sleeves
5. Unusually high or low energy in doing tasks
6. Increased instances of errors
7. Lack of focus
8. Lying or defensive and aggressive behavior
9. Patients reporting little or no improvement in pain, even at higher doses of prescribed narcotics
10. Insisting on taking shifts or caring for patients where there is access to prescribed narcotics
11. Discrepancies in narcotics counts and signing out of wasted narcotics

What should you do if you suspect that a colleague is abusing substances?

When you highly suspect that a coworker is abusing substances while rendering patient care, do not condone the behavior. Stop them from performing care procedures, especially if they are about to administer medications. Sometimes, nurses will cover up for their impaired colleague, particularly if they are friends, but this enabling behavior will lead to more harm for the coworker and more danger for patients. Report your observations to the head nurse immediately. Make sure to follow organizational policies regarding reporting nurses who provide care under the influence of illicit substances.

Posted: 12/8/2017 12:58:10 PM

Does Organizational Change Make You Cringe?

Does organizational change make you uncomfortable as a nurse? Do you find yourself resisting when new protocols are imposed? Have you gone with the flow of change, only to tell yourself that the old way was much better? Or are you a nurse manager who is having difficulty getting the staff nurses to participate in change initiatives?

Change has this primary intention: to improve the current situation and produce a better outcome. As noble as this intention seems, disturbing a process that everyone is already comfortable with is like stirring sand into water. It results in murkiness, and it may take some time before the sand settles down and the water becomes clear again.

In healthcare, change is inevitable, and it is a necessary part of the continuous pursuit to improve services. Nurses find themselves in a position to accept the new way of doing things, even if they are resistant to the idea. But because embracing change will surely be a part of your career as an RN, it will help to consider the following tips to get you through every change process happening in your organization:

1. Be pro-active about being fully informed.

One reason nurses resist change is that they do not have all the information about the initiative. They may hear about the proposal for innovation from a colleague who is against the idea, and the negativity can spread like wildfire. Nurse managers may find themselves frustrated while trying to encourage the staff to participate.

As a nurse, make it a habit to know all the latest updates and understand the purpose for change.

2. Always give feedback.

Providing feedback makes you involved from start to finish. It enables management to hear your ideas so they can make informed decisions about the change.

If, as a manager, you find that a feedback platform is inadequate or missing, suggest an open-structure communication system that will connect management and staff.

3. Be involved during the planning stage.

Make sure to attend meetings that are open to staff during the planning stage. If you are a nurse manager, take the time to represent your unit and make higher management consider your opinions on the matter.

Being involved from the start of a change process makes you excited to know if the initiatives have served their purpose well.

4. Participate in the process.

By this time, you have gained all the right information about the project and you have shared your suggestions. The next step is to give your best efforts to make it work. Be a team player and show enthusiasm. Others will feel your optimism and will likely embrace the new idea, too.

5. Give feedback on how the initiative has impacted you, patient care, and the organization as a whole.

This evaluation will help determine if the project is successful in meeting its goals, or not.

Abandoning an old system and welcoming a new one is not without its hurdles. Many times, it will take a lot of trust, patience, and continued support to sustain the initiative. Being involved from the start is a great way to be motivated to finish the feat that you have been part of, and it also makes you a co-owner of the change. After all the implementations are complete, you can feel proud that you have been a part of a successful endeavor.

Posted: 11/14/2017 12:23:09 PM

Communication Issues in Nursing

Communication failures rank first among the most common causes of medical errors, significantly impacting hospitals and healthcare delivery. And because nurses are at the forefront of patient care, the situation puts the spotlight directly on them.

Communication is crucial in healthcare because it builds trusting nurse-patient relationships and facilitates inter-professional collaboration. Communication must be understood in a different context as that of information. Information is something that you just give out or disseminate, while communication is getting your message across and receiving a reply in the process.

Nurses serve as a common gateway that accommodates the messages relayed among various professionals. Physicians give the orders out and ask about the patient’s condition through nurses. RNs coordinate the care of other clinicians and therapists. Nurses talk to the patient and their families to know their concerns. They act as a liaison between care providers and patients, so their role calls for excellent collaboration skills. When nurses fail to properly communicate, various patient care processes, as well as the interrelationships within the organization, will be on the line.

Here are common communication problems that nurses need to address in the workplace:

1. SPEAKING WITHOUT CLARITY. When there is not enough clarity as nurses speak, errors are bound to happen.

Consider this scenario:

The nurse says to the patient, “Take your pill for hypertension once a day.” The patient obliges. But because the patient considers their diuretic as the main medication for hypertension, the patient took it before bedtime. The next day, the patient complains of a lack of sleep during the night because they were up too many times to go to the bathroom. Being clear, in this case, is saying, "Take one tablet of Quinapril every night before bedtime," while showing them the medication.

2. USING A DISRESPECTFUL TONE OF VOICE. Whether talking with a patient or colleague, the tone of voice conveys the most meaning. If someone says “sorry” without really meaning it, we would certainly know that they are not sincere. A disrespectful tone is a formidable barrier to communication. It breeds anger, resentment, and the need to retaliate. It fosters a culture of fear, where bullying and incivility become an accepted part of a nurse’s job. Additionally, using a monotonous, robotic tone to talk with a patient, conveys a lack of sensitivity and empathy, which will make the patient hold back information and become uncooperative.

3. FAILURE TO RECEIVE OR GIVE FEEDBACK. Receiving feedback makes communication closed-loop. Without affirming that a message is understood, the message becomes open to misinterpretations that can easily lead to errors. Without receiving or message becomes open to misinterpretations that can easily lead to errors. Without receiving or giving a reply, the nurse is simply informing, not communicating. So, if a nurse performs health teaching with a patient without evaluating what they understood, proper communication has NOT taken place. Similarly, when a staff nurse consults the charge nurse and does not receive a reply, they readily interpret this as lack of interest on the part of their supervisor. In a fast-paced environment such as the operating room, it is important to be completely understood as a speaker and to understand clearly as a recipient. Closed-loop communication is tantamount to saving patients’ lives. The success of the unit lies primarily on this concept of collaboration.

4. FAILING TO SPEAK UP. Nurses who consider themselves to be “at the bottom of the food chain” rarely speak up when they see a potential error or become witness to a mistake. Keeping quiet about matters of safety is as dangerous as injuring a patient. Both put patients’ lives in jeopardy. Nurses tend to be quiet when they see that their own interests are at stake if they take a stand, so they choose not to get involved and live with the difficulties. But failing to point out possible areas of improvement blocks the way for solutions and results in both unsafe practices and unhealthy inter-professional relationships.

Nurses cannot be effective in their work if they do not master the art of communication. Failing to get your message across and be understood will ultimately lead to career setbacks and negative feelings about nursing. Proper communication must, therefore, be learned and practiced.

Posted: 9/29/2017 6:48:06 PM

Calmness Within, Amidst Chaos: A Nurse’s True Strength

Have you ever had a day when a patient with several tubes attached to them becomes cranky and uncooperative? Or have you experienced cruising through the morning only to find out that as your shift is nearing its end, you have to change an IV set? Any nurse would say that if they have only these challenges in a day, then they are definitely having a good day at work.

What’s a not-so-good day at work for a nurse look like? Here’s a scenario:

The unit is short-staffed, and several call lights are flashing at the same time. Everyone seemed to be at their wit's end, and their negative vibes fill in the air. You see that patients are waiting to be admitted and discharged. At the back of your mind, you know that something's about to give in, and someone is about to lose it. You think patients are lucky enough to have catheters attached to their bladders because you have been wanting to take a bathroom break for hours now but never had the chance to have one. Lunch? You almost forget what lunch means and what it is for. Missing or broken equipment? That's for dessert.

If there is one word to describe this kind of a day for nurses, it is C-H-A-O-S. When there is a great deal of pressure, and the nurse is still expected to perform safely, that is the ultimate challenge. How can a nurse survive a time like this? Here are some helpful tips for you to reach the end of your shift in one piece:

You never know when a day is set out to be chaotic so anticipate needs. Ensure that you have supplies readily available at the beginning of your shift every day. Think of it as a kit for not-so-good days.

Doctors have developed a way of doing things, and each one is uniquely different in their problem-solving skills. Knowing them in this regard will help you work faster and more effectively with them.

Focus is what separates excellent nurses from the stressed out ones. Getting overwhelmed is a big no-no because it opens all avenues to errors that lead to all sorts of tensions and lawsuits.

When you do safety checks at all times, it becomes a habit. During chaotic times, good habits will enable you to run on autopilot when it comes to safety protocols and keep you focused on more important matters during a hectic day. Critical thinking, on the other hand, keeps you rooted in evidence-based practice even if the going gets tough.

Developing a system of doing things allows you to perform several tasks at the same time. If you are pressed for time, for example, as you count the pulse, you must be making an assessment and evaluation at the same time.

Unless you have a computer for a brain that automatically saves data during accidental shutdown, your best pals at work should be that small notebook and pen that you keep in your pocket. Stress can affect your memory. Having too much going on in a day will make you forget details about the patient, making it necessary to repeat assessments and losing more precious time in the process.

Emergency nurses usually receive training on how to follow triage protocols. If you are an ER nurse, triaging will save more patient lives and will give you a distinct path to follow so that you are still efficient amidst the chaos.

Calmness has to come, one way or the other. Even if reaching the end of your shift seems like an eternity, it will eventually be time to clock-out. It is important to ‘reset’ and replenish, for you know that tomorrow will be another day, another story.

Being a nurse makes you some sort of a superhero with superhuman abilities to remain calm, practice safely, and still be triumphant after a day of chaos. So chin up, embrace the challenge, and be proud of yourself today.

Posted: 9/1/2017 10:39:26 AM

Going Beyond the Zone of a Therapeutic Nurse-Patient Relationship

Patient care is always a part of a nurse’s life, which means that nurse-patient interaction is inevitable. But because the line between therapeutic and social relationships becomes blurry, nurses may find themselves in a dilemma, unable to control the situation and their feelings, and cross the line in the process.

Trust, compassion and mutual respect should rule the nurse-patient interaction so that it is therapeutic to improve the patient’s health, but sometimes nurses fall into temptation, make poor decisions, and disregard professionalism and personal morals. Here are some situations where the boundaries have been crossed in different levels:

- receiving gifts from patients
- doing small favors for patients outside of duty hours (e.g., keeping them company, responding to a neighbor’s
call for help regarding a nursing care they need)
- visiting a patient after they have been discharged just to know their progress
- disclosing a patient’s personal information
- giving the patient personal contact numbers
- inappropriate restraints
- physical and emotional abuse
- sexual misconduct
- dating a patient while still seeking care, or even right after discharge
- having a sexual or romantic relationship with a patient
- sexual advances or suggestions to the patient or vice versa where the nurse consents
- verbal seduction

Of the many instances where nurse-patient relationships become inappropriate, nurses being attracted to patients and then acting on their interest is perhaps one of those behaviors that have early tell-tale signs that they are too close to the edge. Here are some warning signs that necessitate a review of the nurse’s behavior:

- often thinking about the patient even after duty
- spending free time with the patient or spending a lot of time with the patient even if other patients’ needs are
more of a priority
- showing favoritism
- sharing personal information and concerns
- needing to dress more attractively when anticipating interaction with the patient
- asking to be assigned to the patient

Nurses are not the only ones who show their vulnerability. On the other hand, a patient’s behavior can also signal that they are crossing the boundary lines, too:

- the patient demands that they are assigned to the nurse
- they show over-dependence
- they keep asking about the whereabouts of the nurse, or other information from the staff
- they give the nurse special attention, compliments, and gifts

The biggest problem with crossing the boundaries of nurse-patient relationship is that it reduces the benefits of nursing care to the patient involved and the others in their care. It is also clearly a sign of disregard for the Nursing Code of Ethics. These are the reasons why boundary violations are never acceptable.

When nurses find themselves in a situation where they are going beyond the zone of helpfulness, they must be aware of themselves and be quick to review and stop their behavior.

They should seek their supervisor’s help and refer to institutional policies. In receiving gifts, for example, some hospitals will allow small tokens to be received with gratitude right before discharge.

For other behaviors, nurses may check with their respective Board of Nursing and the National Council of State Boards of Nursing. These organizations define professional boundaries and give specific instances where behaviors already are deemed inappropriate.

Nurses also have a duty to report sexual misconduct to the supervisor or the Nurse Manager. These behaviors are never tolerated. Proper documentation must be made, and the misconduct duly reported to the board of nursing, which can take immediate action such as revoke their license.

RNs must also remember that if they became self-aware and educated on professional boundaries, they can prevent violations from harming their patients and their professional career.