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Addiction; Addiction research; Addiction therapy; Substance use disorders; Nurse manager; Work environment; Reintegration; King’s model; Interpersonal relationship; Standardized protocols

Substance use disorder (SUD) among nurses is a significant issue because of the risk for impaired practice and patient endangerment [1]. Preliminary report suggests that the persistent use of illicit substances among nurses first appeared in the 1900s and this was associated with working in a critical care areas or specialty, access to drugs, job-related stress, depression as well as knowledge of the substance being abused [2]. Kunyk [3] observed that most nurses who were at a higher risk for impaired practice due to substance use were in active service, unknown to their employers and were not receiving any treatment. This report further suggests that these nurses were unwilling to disclose their drug-seeking habit to the employers for fear of losing their license and/ or being stigmatized. Alcohol and other substance use by nurses potentially place all service users at risk for poor quality of care and harm. Nonetheless, when SUD is viewed and treated as a chronic medical illness, treatment outcomes are comparable with those of other diseases and can result in lasting benefits [4].

The nurse manager plays a critical role in situations involving a nurse with SUD. However, the nurse manager can support in the treatment of a nurse with SUD if only he or she understands their own attitudes towards the affected nurse’s impairment. One of the nurse manager’s role is his/her ability to keep all service users safe, whiles maintaining high standards of care and professionalism on the nursing unit. Nurses on the unit may be unaware of the signs of SUD or may be uncertain about what to do, not wanting to jeopardize the career of a colleague. It is the responsibility of the nurse manager, to educate them, dispel myths and act responsibly. The Addiction Disease Unit (ADU) of the ministry of health, Ghana reports a disturbing trend of the increasing number of nurses with substance use disorders on yearly basis which threatens the safety of service users.

Conclusively, the study sought to understand and describe the nurse manager’s experience of nurses with substance use disorders as well as how these nurses are re-integrated into their respective departments after they have been treated successfully.

A qualitative descriptive exploratory approach was used to describe the experiences of nurse managers of nurses with substance use disorder (SUD).

Population

The target population for this study was nurse managers of nurses with substance use disorders. However, Nurse Managers who have never had an encounter with a nurse diagnosed with substance use disorder were excluded from this study.

Sample size

Purposive sampling was used in identifying and selecting the participants for this study. A total of five (5) Nurse Managers who have worked with nurses diagnosed with SUD were purposively selected for the study.

Data collection instruments

Data was collected using an in-depth face-to-face interview by means of interview guide. The interview guide contained openended questions which were developed based on the study objectives, construct of King’s model of goal attainment as well as literature review.

Data collection method

Participants (Nurse Managers) interviewed. The interviews were recorded with a digital voice recorder and were later transcribed. Participant’s non-verbal behaviour was recorded in field notes to provide further context to the result.

Prior to conducting the interview, participants were recruited through their staff they were working with. The participants were initially contacted at the study area for their willingness to participate in the study, followed by setting an appointment. The location and time were at the convenience of the participants. Participants were assured that, the interview will be conducted in accordance with the COVID-19 prevention protocols, given information which contained issues primary to the study, including statements assuring confidentiality, purpose of the study, context in which the interview will be conducted and the participants right to withdraw from the study at any point willingly. Participants were also made to read, agree and sign a consent form.

Data processing and analysis

The data analysis included verbatim transcription of data (read several times to gain enough understanding of the participant’s view), data reduction (coding, categorizing, and summarizing) to develop themes which were reviewed to ensure the participants’ opinions were well represented. The information gathered was interpreted in accordance with the objectives of the study.

Participants

The demographic characteristics of the participants included participant’s age, gender, and years of service. Five (5) participants were interviewed in this study, out of which four (4) were females and one (1) was male. Their ages ranged from 53 to 59 with an average age of 56. All of them being nurse managers of the various departments who have worked for at least twenty-seven (27) years. For confidentiality purposes, all participants were given pseudo names (codes).

Themes

Thematic areas were developed from king’s conceptual framework and the subthemes were consistent with the description of each construct of the model. Sequencing also correlated with the description of the construct of the model, that is, personal concept, interpersonal concept, and the social concept. Four (4) major themes emerged from the data with eight (8) sub themes. One (1) major theme associated with two (2) sub themes were derived through a comparison of researcher’s cluster of themes. There was consistency in most of the coding with minor revisions to the subthemes.

Results

Perception

Participant’s accounts suggest that they least expected nurses to be using illicit substances, so they were surprised at the knowledge that a staff working under them has substance use problems. A participant indicated that, she was very shocked and did not know what to do. She narrated: “Very shocking when I realized one of my staff was using drugs. I really felt sorry for this staff, the parents were not even aware about whatever is going on, they think it is because of the work that when they come home, they go straight to their rooms without interacting with anybody” (ENM 001). Another participant also said, she felt bad and tried to understand the staff. She indicated: “I felt bad, but I tried to understand her, made her comfortable and assured her of total confidentiality and trust” (ENM 004).

View (Body image)

Some participants viewed nurses with substance use disorder as having both a moral deviation and a disease at the same time. One participant stated that, the culture of the person may expose him to the drugs, but excessive use will affect the brain function. She states:

“I will take the two, let’s look at the family, if the nurse, grew up in a culture that permit drug use, then it will be normal but taking it to that extreme, it will elude the person until the person get to the field, study the drug and realize that, all these I have been doing to my self is not good and withdrawing too has some effect if you don’t have the will power. A disease too on the other hand that, taking the drug in excess will definitely affect your brain function, do you get it, it affect your judgment, the way you look at things is different, the way I will describe the legs of an elephant will be different from the way a nurse with SUD will describe the same elephant, I may be seeing the normal legs and he or she may see them as pillars the body will be a war for you because, the pupils have been so dilated that, you are seeing the thing differently from the normal perception” (ENM004).

Some participants also described addiction as a disease and whoever is affected needed treatment. One participant recount that, they used to think it was a moral deviation but now they know it is a disease thanks to workshops they attended on addictions. She narrates: “Oh! It is a disease. Formally, that was our thought, that it is a moral deviation but going on through the knowledge, workshop, now we have a changed mind set, so, it is a disease” (ENM 002).

It was observed from the narratives that, many of the nurse managers did not expect to see nurses having substance use disorders, even though a few said it is a disease and can affect anybody, for that matter nurses who are affected needed help.

Interpersonal systems

According to King [5], people usually come together in a health care organization to help and to be helped to main a state of health that permit functioning in roles. This theme therefore sought to find out how the nurse managers interact with the nurse with SUD and the role they play in helping them find recovery.

Interaction

Narrations from participants show that, they all became concerned and gave more attention to their staff (nurses) diagnosed with substance use disorder. Here is what some of the participants had to say: “We go closer to them, when you get to find out. Let the person trust you, one on one, show care and they will confide in you” (ENM001). Likewise, another participant indicated: “I will be asking her how she is, and the home as well. She complains about her mother being overanxious and going through her things in her absence. I always tell her that, yes, it is because your mother loves you and wants you to continue with your sobriety. I also opened to her, told her she can always come to me if she has issues or problems to discuss or difficult problem she can’t handle, so we see how to handle it. Gradually, I realized, she was up to the task” (ENM002).

Role

All participants indicated that, they helped the nurses upon knowing that the nurses had substance use disorders. One participant commented: “When we realized, we stopped her from collecting the money at the OPD, and added another person to her, so she is no longer in charge of the money. We also announced to other people at the department that, she owes the department so nobody should give her money. (ENM001).

Similarly, another participant narrated: “I know what the implication of not helping her means, I know my job, I was focused, not demoralized or demotivated, mine is always to advocate for the best for not only nurses but all my client. I knew and I saw that she can recover and do well and make the change. I must be honest with you, the number of nurses who are doing well is so much a motivation that, I continue to advocate over and over again. Now what I did to help this nurse was to get her moved from OPD to institutionalized, I ensured she didn’t pay the full amount sine she didn’t have money, and I am glad to say that she is doing well and has even come to apologize for putting a fight with me” (ENM003)

From the above narratives, it was noted that participants (Nurse Managers) had good interaction with the nurses with SUD. However, the participants did not have a standardized procedure of helping the nurses.

Social systems

This theme sought to find out what measures the organization has put in place to support their staff in general that happen to have drug addiction problems mostly for nurses and how well they are implemented [5].

Organization

The participants indicated that their respective departments did not have any protocol in place be it written or unwritten that serves as a guide to manage colleagues who have been identified as having substance use disorder. In relation to this, one participant narrates “Those who do not get the needed help do not come for treatment. Some are brought by relatives; they find a way of getting them into treatment. But here at ADU. the problem that I have is that, after treatment they don’t want to take them back into their various department that they were brought from, they want them to be retained here and that is not recovery, and it has been a debate over the years. Sometimes I try to convince and the next thing I hear is that they write a long letter transferring the person to work at the ADU and I think that is not good enough (ENM003). Another participant commented: “No, there is no protocol, but I believe strongly that, there should be a protocol, developed by the institution, again, there should be a mechanism in place to help screen nurses before they are recruited so that those who are already using can be identified and isolated” (ENM 004).

Decision-making

Some participants indicated that, the decision they make concerning the treatment and re-entry of the nurses with substance use disorder back to the workplace depends on the advice of the Addictive diseases unit. Here is what one participant narrated: “Their re-entry is also based on the advice from the addictive disease unit, they will tell us because of how far they have gone, the person should re-enter gradually in terms of number of days the person has to work, the number of visits the person has to make to the addictive disease unit and we work with them till the person is able to fully recover” (ENM002).

This is what one participant said: “Yes, I will take a nurse back but she will do mostly paper work or, I will make her work strictly under me hand in hand, so as to safe guard the patient safety because she knows I am monitoring. If the person is not taking back anything can happen, she can even be suicidal” (ENM004).

Another participant commented: “I think you have to change the person to another place. Out of sight, out of mind, so you must take her to where she will not see it not smell it, but then, again, it is the self. Some people in recovery will come back, see these drugs and will not touch again, so even though the environment plays part, it is the individual. Sometimes stigma prevents us from sending the person to the same place where she was originally working. To help the person out, you take the person out of the old place because she will not feel” (ENM001).

It was clear from the narratives that, participants had no protocol on how to manage a nurse with SUD neither do they have a procedure in place on how to debrief other colleagues who may have been affected by the actions and inactions of the nurse with SUD. Decisions made to help the nurse with SUD seek for treatment and possible re-entry into the workplace is made by the nurse managers.

Knowledge

Lack of knowledge about the facts surrounding SUD contributes to negative stereotypes about those suffering from SUD. Since these stereotypes can negatively affect the recovery process of the nurse, education is the first step in creating a culture of acceptance and understanding about colleagues with SUD. Addiction among nurses can be managed and treated if the nurse manager is able to recognize the manifestations of a person using substances and his ability to notice certain behavioral clues. This theme sought to find out the nurse managers’ knowledge on substance use and its related manifestations.

Idea on SUD

Almost all participants had a fair idea on what substance use disorders and its related signs and symptoms. In view of this one of the participants narrated: “SUD’s technically, is a chronic relapsing brain disease characterized by compulsive seeking and use of substances despite the harmful consequences and the consequences could be biopsychosocial, psychological or even spiritual implications” (ENM003).

Another participant also indicated: “SUD, what I know is that, is a type of condition where the one involved uses this substance without any prescription. They take it on their own and then gradually they become addicted to it such that, without the substance they are not able to work and adapt to society” (ENM002).

Again, commenting on their knowledge about SUD, this is what one of the participants stated:

“That compulsive use of chemicals or drugs and alcohol, doing it repeatedly you crave all the time for the chemical and you become addicted, and it cut across globally and nurses are not exception. People will think we don’t have problem, but we have a lot of problems but when we come out to complain, most of the times, the doctors will feel, maybe it’s because of excuse duty that we want’’(ENM004).

Identifying signs and symptoms of SUD

Almost all participants were able to describe the signs and symptoms of substance use disorders. One participant indicated: “Of course, I will be able to tell, because if you are working with somebody and there is a change in attitude, you should be able to tell, and to be able to tell, you have observed that person and get some of other colleagues to observe to confirm that this person is on substance (ENM003).

Some nurses come to work earlier than normal, with extra clothing always complaining of feeling cold, some easily get aggressive at the slightest provocation, some too whenever they are around, you realize medication get lost like pethidine, this happens whenever the person is on duty. Some of them will always be asking of soft loans, small monies and you observe that some of them their skin color has changed” (ENM 001).

Interestingly, one participant indicated that she can only recognize a staff is using illicit substance if it is at the addictive or dependency stage.

It is observed from the narrative that, all participants had a fair knowledge about what substance use disorder is and were also able to describe the manifestations at the dependency or addictive stage.

The purpose of this study was to explore the experiences of nurse managers of nurses with substance use disorder and how these nurses are re-integrated into the working environment. The findings were discussed under four themes: Personal, Interpersonal, and Social Systems and Knowledge. King’s conceptual framework was used as the guiding model for this work. The objectives of this study explore the nurse managers’ opinion about nurses with SUD, describe the interpersonal relationship between the nurse manager and the nurse with SUD, and identify the social interventions established by the institutions to help nurses with SUD as well as to inquire about the nurse managers understanding on SUD.

Within the 'Personal Theme' most nurse managers saw the nurses with substance use disorder as having a moral deviation. This observation is inconsistent with Kubayi’s [6] findings where most of the nurses perceived SUD as a disease, medical condition and not a moral deviation. This contrast could be due to the relatively small number of participants involved in the study, it could also be due to the design, a qualitative design was used, whilst Kubayi used a quantitative design. However, all the participants indicated that, the disease component of substance use is treatable and there is the need to give nurses with SUD the needed support.

This reconciles with preliminary studies that suggest that nurse managers perceive the need to support the nurse with SUD using humanistic approach to provide same [7,8].

In furtherance, within the 'interpersonal system or theme' the nurse managers became concerned upon receiving the news of their staff having SUD, they drew closer to them, showed interest in them, and found ways to help. Again, this observation resonates with reports of prior studies that indicate that nurse managers have the responsibility of keeping both the patient and staff safe, educate them, dispel myths and take action when needed, being proactive and having empathy for these nurses [3]. Nurse Managers play a significant role in addressing substance related issues among nurses and can be key to influencing the outcomes of these difficult situations. Also, most nurse managers were willing to help nurses re-enter into the workplace and are ready to work with them. This finding is consistent with a survey by Cook [7], where nurses were ready to work with the nurse in recovery. Cannon and Brownreported similar findings where more than fifty percent of the nurses were most likely to support a recovering nurse re-enter into the workplace.

With regards to the 'social theme', it was observed that, even though nurse managers were willing to help the nurses with SUD, there was no standardized policy or protocol for engaging and dealing with or helping these nurses with SUD. Perhaps this is why the nurse managers use their own decisions to help the nurse with SUD to the best of their knowledge this is in contrast with preliminary reports. Comer, et al. [9,10] that suggest that institutions and organizations need to play an active role to ensure there is alternative to discipline programs that work effectively for nurses with SUD. The nurse managers had no knowledge of any employee-assisted program in the facility to guide their decisions. Nurses who suspect a substance use disorder in a colleague need to be provided with guidelines on how to report their concerns in a confidential and non-threatening manner. This will increase the likelihood that substance use problems are detected earlier and dealt with appropriately.

Interestingly, all nurse managers had a fair idea about what substance use disorder is, however only one could identify a nurse with SUD at the initial stage, whiles the other respondents opined that it will be difficult to do so at the initial stages. Nonetheless, the addictive or the disease stage was easy to identify. This is consistent with reports that indicate that most nurses with SUD were working unknown by their employer and immediate managers and not receiving treatment [3, 11].

In summary, most nurse managers perceived substance use disorder as a moral deviation which only becomes a disease at the addictive stage, they however, showed concern, became interested and willing to help upon discovering that a staff has SUD. Helping the nurse with SUD was however, done per the nurse manager’s discretion or in consultation with other colleagues since there was no organizational protocol or policy arrangements in place to follow. Most of the nurse managers were however, willing to accept the nurse with SUD and in recovery back into the work place and work with them while a few were against receiving them back into the unit where they were previously worked. This may be due to stigma and fear of the nurse with SUD having a relapse upon encountering their triggers. Lastly, even though the nurse managers had a fair idea about SUD, early identification of SUD in a staff was a problem as only one of the nurse managers admitted can identify the signs and symptoms at the initial stage [12-20].

Implications of the study for nursing practice

The findings of the study have some implications in relation to nursing practice, nursing education, nursing research and policy formulation. Nurse Managers will always be the frontline employees whose role put them at the core of the healthcare delivery. Hence it is very important all nurse managers are trained on how to identify behavior clues in their staff with SUD and intervene early and assist with the re-integration of the affected nurse into the workplace appropriately. Similarly, education on substance use and addiction should be given to nurse managers prior to assuming the administrative position and should be part of ongoing professional development programs in health care institutions. Student nurses need to be well equipped on what substance use is, how to identify a colleague who has a problem with the use of illicit substances and how to report while in school.

Conclusively, the data from this study could be used to help guide nurse administrators in developing policies and protocol guidelines in the early identification and referral of the nurse with substance use disorder into the treatment programs [21-25].

Funding

No funding was secured for the study

Ethical statement

This study was approved by the relevant institutional body where the study was conducted. All participants enrolling in the study completed a written consent form after the purpose of the study have been explained to them.

Consent for publication

Not applicable

Availability of data

The dataset used and analyzed during the study can be obtained from the author on reasonable request.

Authorship statement

I wish to inform the editorial board that this manuscript with the above title was solely carried out and written by myself. I therefore claim full ownership of the content and any other issue related to it.

Acknowledgement

I wish to acknowledge the staff and management of the Korle- Bu Teaching Hospital for their immense support and contribution including the subjects who participated in the study.

Disclosure statement

The author wishes to state that there is no conflict of interest related to this research. The research received no funding or specific grant from any funding agency, commercial or non-profit sector. The author also asserts that all procedures contributing to this work comply with the ethical standards and principles of the relevant institutional and national committee.

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