When my buddy Jason first got into his nursing
program, I was excited for him. Nursing is an honorable profession, one that is
constantly in demand and provides certain stability that other career paths may
His first few semesters were rough, understandably.
The competitiveness of his nursing program, the long clinical hours, and the
constant full exertion required eventually took its toll on him.
By the time he became a nurse, I hardly saw
him at all. He began to ignore our invitations to go out with friends and to
get defensive whenever we gave him a hard time about it.
When we finally did see him, he was always on
edge, flighty, and nervous. Many of our friends began to question his mental
health but I knew what had happened.
Jason was struggling with addiction.
All of the signs and symptoms were there, as
were the growing pressures that led him to an addiction.
It didn’t take long for my friend to seek help
and eventually sober up. He was committed to his role as a nurse and even more
committed to providing the healthcare that he promised to provide once he
received his license.
But with my work in addiction recovery, it
became apparent to me that this was a real epidemic both in the general
population and among nurses. If you’re not sure whether or not you or someone
you know is struggling with addiction, then read through for symptoms of
addiction and withdrawal to find out.
I’ll also outline some ways to provide support
so that the nurse in your life can get back to the job they love so much
without the dangerous effects of an addiction.
Substance Abuse in the Medical
Profession Versus General Population
Surprisingly, dependence on alcohol and drugs
for nurses isn’t too far off from that of the general population. While some
may assume that nurses would stay away from an addiction, about 10 percent of
nurses struggle with an addiction of some sort.
Considering that there are about four million nurses in the US
alone, roughly four times the amount of physicians we have, it’s a staggering
number of medical professionals who are in the throes of addiction.
As the shortage of nurses continues to rise,
so does the job stress and lack of resources to support them.
Nurses have been tasked with roles that are
traditionally performed by physicians and are expected to work long hours in
constantly rotating shifts, making the work environment for nurses especially
Plus, they have easy access to virtually any
prescription pill on the market.
But because they work with medications so
regularly, many of them have intellectualized use and abuse to the point of
failing to recognize when they themselves are addicted.
Symptoms of Opiate Addiction and
There are several different things to look
for, though signs and symptoms can generally be broken down into two
categories: signs of intoxication and signs of withdrawal.
Signs of opiate intoxication generally
- Feelings of euphoria
- Pinpoint pupils
- Nausea or vomiting
- Poor memory and concentration
If any of these signs appear when they were
previously absent, then it’s possible that this person is battling an
Signs of opiate withdrawal include:
- More vomiting and nausea
- Muscles aches and pains
- Intense anxiety and/or panic
- More sweating
- Extreme irritability
While some of these symptoms can be present
due to lack of sleep and stressful situations, they tend to be a bit more
extreme in those experiencing withdrawal.
Another thing to watch out for that is super
specific to nurses is whether or not this person is offering to cover more
shifts than usual. While most people would try to get out of work, an addict in
the medical field might ask for more work opportunities so that they have more
access to their drug of choice.
In either case, whether intoxicated or
experiencing withdrawals, an untreated chemical dependence such as this can
impair judgment, slow a person’s reaction time significantly, and increase
life-threatening errors that may harm a patient.
How to Support Someone With
Nurses have had to work exceptionally hard to
get to where they’re at professionally. Understandably, many nurses have a
touch of perfectionism. Though this makes them excellent students and even
better nurses, it can sometimes make the recovery process a little challenging.
Perfectionism in addiction recovery is
actually a pretty common issue, according to (Detoxes)
. And though perfectionism is generally a helpful trait, it can get in the way
Rather than expecting perfection out of your
friend or colleague, try a few supportive approaches, instead. Consider that nurses addicted to drugs have
unique cases where a recovery program may prevent them from continuing to work
as a nurse, at least during their recovery period. Also consider that there
might be a lot of shame surrounding the addiction, or that the person may not
recognize the addiction at first.
Approach the topic gently and explore all
options for a full and safe recovery.
For full support and guidance, the Substance
Abuse and Mental Health Services Administration (SAMHSA)
has put together a handful of resources to help you navigate the recovery
My buddy Jason was fortunate to be able to
heal from his addiction and I hope for the same for all nurses struggling with
addiction. The first step to ensuring this is to recognize that the risk exists
right in your own station.
The author, an addiction recovery advocate, requested anonymity for publication of this piece. Names have also been changed for anonymity.
From 2014 to 2017, physician burnout increased by 5% at the Massachusetts General Hospital Physicians Organization in Boston, according to a recent analysis.
Other research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The research published in JAMA found exhaustion and cynicism were the primary drivers of increased burnout at Mass General. The research was based on survey data collected from more than 1,700 physicians.
The survey data showed exhaustion increased from 52.9% in 2014 to 57.7% in 2017, and cynicism increased from 44.8% in 2014 to 51.1% in 2017.
The exhaustion finding was particularly troubling, the JAMA researchers wrote. “We found physicians were more vulnerable to emotional exhaustion than any of the other subscales of burnout. Physicians reporting high levels of exhaustion were more likely to reduce their clinical schedules, reduce the number of patients in their practice, leave the practice, or retire.”
The researchers noted that physician turnover has several costs including patient and clinician distress as well as the expense of replacing physicians, which can be as high as three times a doctor’s annual salary.
Primary care physicians reported higher levels of exhaustion compared to medical specialists. “These findings may be associated with the amount of time primary care physicians spend documenting on the EHR and serving as the clinicians responsible for the management of patients’ multiple complex medical and social problems,” the researchers wrote.
Burnout data points
The JAMA article has several other key data points:
- Early-career physicians who had less than a decade of practice experience since their training were more susceptible to burnout than veteran physicians.
- The higher burnout rate in 2017 may be linked to implementation of a new electronic health record system because average time devoted to administrative tasks increased from 23.7% in 2014 to 27.9% in 2017, and increased time spent on administrative tasks was linked to higher burnout.
- Several favorable working conditions were associated with lower odds of burnout: workflow satisfaction, positive relationships with colleagues, time and resources for continuing medical education, opportunities to impact decision making, and having a trusted adviser.
Addressing physician burnout
The lead author of the research, Marcela del Carmen, MD, MPH, explained that the physician group has implemented several efforts to reduce burnout.
“We have allocated funding to each of our 16 clinical departments to develop and institute initiatives to mitigate burnout in their departments. We have central efforts including sponsoring social events to enhance connectivity amongst the faculty, efforts to improve our use of the electronic health record through personal- and practice-level training, and funding to support peer-to-peer coaching programs, yoga, and meditation sessions.”
Del Carmen’s research team also suggested that burnout prevention efforts could be tailored for early-career physicians, who reported relatively high dissatisfaction with department leadership, relationships with colleagues, quality of care delivery, control over work environment, and career fit.
“These findings point to potential opportunities in this vulnerable group to mitigate burnout, such as initiatives that promote community building and networking and harnessing effective leadership,” the researchers wrote.
This story was originally posted on MedPage Today.
CBD (cannabidiol) oil is a popular cure-all that you may have seen hyped or scrutinized by the media. But what exactly is it, is it safe, and how is it different from the use of medical marijuana?
THC, CBD, and Hemp
Marijuana comes from the leaves of the Cannabis plant, which produces a variety of active chemical compounds referred to as cannabinoids. There are dozens of cannabinoids; THC (tetrahydrocannabinol) and CBD are two of the more widely studied. THC is the psychoactive compound in marijuana that causes intoxication, or a high, by activating the brain’s reward and pleasure center, causing the release of dopamine. By contrast, CBD is not psychoactive and therefore does not cause a high. It is also not believed to be addictive.
Hemp also derives from Cannabis, but generally refers to plants cultivated for non-drug use. Hemp also contains much higher concentrations of CBD and a much lower concentration of THC (<0.3%). Historically, hemp has been used to make rope, fabrics, or textiles.
Medical marijuana is now legal in 33 states and the District of Columbia. For recreational use, marijuana is legal in 10 US states and in DC. In recent years, the number of patients who are turning to Cannabis for medical treatment is increasing. Marijuana has been a therapeutic treatment for cancer patients; it has been shown to treat pain, nausea, and cachexia. Marijuana is also now used as a treatment for Alzheimer’s disease, chronic pain, Crohn’s disease, and many other conditions.
CBD is generally sold formulated into an oil and has been touted as a solution to pain, insomnia, anxiety, and a wide range of other medical conditions. CBD oil is expected to become a billion-dollar industry in coming years. It is important to note, however, that despite the oil’s growing popularity, it remains largely unstudied and unregulated.
CBD is readily available for purchase online, but it has varying levels of legality in the United States. Although several US states have specific laws regarding CBD, it remains a controlled substance by the Drug Enforcement Agency, and is classified as a Schedule I drug. This designation remains despite the passage of the 2018 Farm Bill (which legalized the broad cultivation of hemp, under outlined restrictions).
There is a lack of high-quality, large-population studies on CBD use in humans. Large-scale, randomized clinical trials are needed, but it has been proposed as a potential therapy for a range of conditions, including anxiety, Parkinson’s, chronic pain, schizophrenia, and multiple sclerosis. Many users anecdotally claim it has pain-relieving benefits and use it as a treatment for muscle aches, inflammation, and pain. Other people use it to ease anxiety and insomnia.
There currently exists only one FDA approved medication that contains CBD: a seizure medication called Epidiolex, which is used to treat two particularly severe seizure disorders in children.
CBD is most commonly available in the form of an oil or drops. It may also be formulated into a balm, patch, or topical. There are also edible formulations, such as chewing gum, gummies, cookies, and brownies.
It is not likely that a patient will mention the use of CBD oil during a medication reconciliation, so it is important to ask patients about all products they use, including herbs, supplements, and oils. Patients should know that CBD oil may interact with other medications (such as blood thinners), and it could potentially increase the level of certain drugs in the bloodstream. Although side effects are anecdotally infrequent, it may cause sedation, fatigue, or nausea or diarrhea.
Patients should be informed that the concentrations of CBD oil vary widely, not just from product to product but also from bottle to bottle. A 2017 study published in JAMA found that of 84 different CBD oils purchased through online retailers, 18 actually contained THC. Moreover, 43% of the products were underlabeled (that is, the concentrations of CBD were lower than listed on the product), and 26% were overlabeled (the concentration was higher than listed).
Additionally, because there have been no large-scale studies of CBD in humans, there are no recommended safe or effective dosages.
Nursing is a unique profession, with major psychological stressors and equally great emotional benefits. Who would have better self-care tips for you than a psychiatric nurse practitioner and DNP candidate? Jonathan Llamas DNP (c), BSN, RN-BC, PHN, is all that, plus a freelance writer for MinorityNurse.com.
Llamas is pursuing his degree at Loma Linda University while also working full-time as a psychiatric-mental health nurse at Kaiser Permanente in Los Angeles, CA. (Obviously, he knows a thing or two about workplace stress!) He is a Filipino-American, a first-generation college graduate, and an emerging nurse leader who aims to help educate the next generation of nurses.
In this Q&A interview, Llamas suggests ways for nurses to practice self-care, while at any point in their career journey.
Jonathan Llamas DNP (c), BSN, RN-BC, PHN
How did you become interested in psychiatry?
I ended up choosing psychiatry because at an early age, I have always been fascinated by the miraculous wonder of the human mind and the inherent beauty and evolution of life that emanates from the adept functioning of the brain.
I developed a profound passion to better understand and treat the psychological, emotional, and spiritual ailments that are often associated with mental illness in contemporary society.
What have you learned—related to stress, self-care, avoiding overwhelm, depression, or burnout—from your psychiatric nurse training that you wish all nurses knew?
The most important concept that I have learned so far during my experience working as a psychiatric-mental health nurse is the importance of self-care. The concept of self-care was never really endorsed until recently, because of the overwhelming influx of individuals suffering from mental illness in recent years.
The interesting part about mental illness that many people tend to forget is that it is non-discriminatory—meaning that it can affect anyone regardless of their race, gender, creed, or socioeconomic background.
I often make it a point to encourage my fellow nurses and colleagues to not be afraid to care for their mental health and address any issues that may produce additional stress and anxiety in the future.
What personal benefits (emotional, psychological, spiritual, etc.) have accrued to you from pursuing this specialty?
Working in psychiatry is a unique experience because it teaches you a lot about the interplay between the emotional, physical, and psychological components of holistic treatment. As a result of this realization, I try to make a concerted daily effort to continue to develop not only creative approaches to my nursing care, but also empathetic techniques that ensure patient safety and satisfaction is achieved across the patient gamut.
You also have previous experience in ICU/trauma and ER settings—what did you learn from those roles, related to stress, overwhelm, and so on?
Although it can be physically and emotionally draining, working in the ER and ICU/Trauma settings—[they] taught me the significance of perseverance, collaboration, and patience.
I have come to learn that the best way to combat stress and burnout is to surround yourself with people and hobbies that energize and remind you as to why you chose to be a nurse in the first place.
Do you have favorite techniques for de-escalating difficult situations, with patients or coworkers?
In the past decade or so, violent incidents have increased dramatically and are now four times more likely to occur in health care than in any other private industry.
Because of this unfortunate reality, one of my favorite de-escalation techniques that I continually perform on a consistent basis is the LOWLINE Model. (Described by Mike Lowry, Graham Lingard, and Martin Neal in a 2016 Nursing Times article.)
LOWLINE is a mnemonic that stands for (L)isten, (O)ffer, (W)ait, (L)ook, (I)ncline, (N)od, (E)xpress.
How has being a minority (gender or racial, ethnic, etc.) nurse played out in your career?
Surprisingly, being a minority male nurse in a predominantly female driven profession has been a positive experience for me thus far. Although I can only speak on my own personal experience, I consider myself blessed and fortunate to be able to care for my patients without fear of being judged or discriminated for my racial, ethnic, gender, or socioeconomic profile.
Since I do work in psychiatry however, I do experience the occasional irreverent name calling from highly psychotic patients, but I do my best to not let it affect me and compromise the type of nursing care I provide.
Listen to Jonathan Llamas on mental health nursing in an “Alumni Spotlight” video clip.
Changing perceptions of risk could improve compliance with infection-control measures
It’s often said that knowledge is power. But a new study finds that when it comes to nurses’ compliance with infection-control measures, it’s more appropriate to say attitude is everything.
The study, published in the American Journal of Infection Control, examines the relationship between infection-control compliance, knowledge, and attitude among home healthcare nurses. Researchers surveyed 359 home healthcare nurses in the U.S., and evaluated their knowledge of best practices in relation to their compliance with infection-control measures.
Over 90% of nurses self-reported compliance for most of the measured behaviors. The researchers also found there was not a direct correlation between knowledge of infection-control practices and compliance with those practices. However, there was a relationship between the level of compliance and the participants’ favorable attitude toward infection control.
“This study tells us that knowledge is not enough,” said one of the lead authors, Jingjing Shang, PhD, of Columbia University School of Nursing in New York City. “Our efforts to improve compliance need to focus on ways to alter nurses’ attitudes and perceptions about infection risk.”
The authors suggest that efforts to improve compliance with infection-control practices should focus on strategies to alter perceptions about infection risk. Changes should start on an organizational level, and seek to create a culture of positivity in relation to infection-control compliance.
Among other takeaways from the study:
- Protective equipment lapses: While most of the participants reported compliance on most issues, many reported lapses when it came to wearing protective equipment; only 9% said they wear disposable face masks when there is a possibility of a splash or splatter, and 6% said they wear goggles or eye shields when there is a possibility of exposure to bloody discharge or fluid
- A culture of “presenteeism:” Presenteeism, coming into work despite being sick, has become a patient safety issue over the last few years, especially as it relates to infection control; only 4% of participants felt it was easy for them to stay at home when they were sick, which could be a major contributor to rates of infection
- Hand hygiene is still an issue: 30% of respondents failed to identify that hand hygiene should be performed after touching a nursing bag, which could transport infectious pathogens as nurses travel between patients
“Infection is a leading cause of hospitalization among home healthcare patients, and nurses have a key role in reducing infection by compliance with infection-control procedures in the home care setting,” Shang said.
This story was originally posted on MedPage Today.
As we described in Part 1 of this series, there are important ways for nurses to speak with other providers in order to keep their patients safe. Likewise, there are crucial strategies for them to use when speaking with the patients themselves.
Again, Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can safely communicate with patients.
What strategies can nurses use when communicating directly with their patients in order to keep them as safe as possible?
Effective communication with patients is just as important to ensuring positive outcomes in high-risk situations. Patients seek out health care for personal and often complicated medical conditions. They can be fearful, concerned, uncomfortable, worried, or even terrified when they visit a health care facility. Be mindful of your patients’ emotions and how these emotional states will affect the way they describe their symptoms and problems, how they interact with you, and how information and instructions are received.
The following list of patient communication strategies is straightforward and can be incorporated into any conversation with a patient:
- Start with a warm introduction. Some providers walk into a waiting room and introduce themselves to their patients. This makes patients feel important. It indicates that the provider is not in a rush and is taking the time to greet them rather having them ushered into an empty exam room by office staff.
- Greet the patient by name. Greet patients by their formal name. “Hello Mrs. Jones, I am Cathy and I’ll be your nurse today.” If you prefer to be less formal or you know the patient well enough, use first names. By nature, people like to hear their own names. When you know and use patients’ names throughout the medical process, stronger bonds and relationships are created.
- Make eye contact. This feature of a personal interaction cannot be underestimated! If you don’t make eye contact with patients, they may assume that your thoughts are elsewhere or you are not interested in their medical issue. Eye contact is a sign of confidence, and patients want to feel confident that they are in good hands.
- Be engaged. Patients know when you care, patients know when you are prepared; and patients know when you are authentically engaged. Consistency of communication is an art. Whether you are stressed, fatigued, or otherwise preoccupied due to any number of reasons, you must learn the art of being consistently engaged with all patients.
- Listen to and acknowledge patient concerns. It is important that you listen, understand, and acknowledge what patients are saying. Take time to ask appropriate questions to ensure that important pieces of information were not overlooked by the patient. When you take the time to listen, miscommunication is–for the most part–averted and medical errors are significantly reduced.
- Avoid interrupting the patient if possible. Allow the patient to finish explaining. Physicians and nurses often interrupt patients with questions in the middle of a conversation. Let patients complete their thoughts before questioning further. If patients go off on a tangent, politely interrupt and refocus them on what needs to be communicated.
- Confirm understanding via “teach-back.” Rather than asking patients if they understand their health issues, intervention plans, or any aspect of their care, it is often more efficient to use an easy technique such as “teach-back” to confirm full comprehension–have them repeat what they understood. Simply ask the patient something like: “Mrs. Jones, since you will be taking home three different medications, just to be sure you fully understand the instructions, please explain to me how and when you will take each one.”
- Provide patients with written instructions. Patients are often overwhelmed with news of a diagnosis or the seemingly complex plans for home- or self-care, which includes taking medications. Preparing and distributing written instructions will help avoid misunderstanding of the treatment and follow-up plans.
What else do nurses need to know about communicating effectively to improve patient safety in high-risk situations?
Data from The Joint Commission consistently reveals that poor communication is a leading cause of medical mistakes that result in patient harm. In fact, during the years 2014 and 2015, communication was the third most frequent “root cause” of all sentinel events reviewed.
Medical errors continue to plague our health care system. Many of these mistakes cause significant patient harm and often result in malpractice litigation. Communication breakdowns, rather than a lack of provider skill and/or medical training, are responsible for far too many adverse events. The good news is that we now have simple techniques that can be easily utilized to improve nursing communication and decrease medical errors.