Текст книги "The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital"

Автор книги: Alexandra Robbins

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Текущая страница: 20 (всего у книги 33 страниц)

Chapter 7

The Code of Silence

:

Painkillers, Gossip, and Other Temptations

“I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.”

–The Florence Nightingale Pledge (a nurses’ adaptation of the Hippocratic Oath)

“It’s insanely easy to steal medications. There have been plenty of times where I’ve emptied my scrub pockets at home and found ketamine, Dilaudid, morphine, and Ativan.”

–a Texas ER nurse

LARA

  SOUTH GENERAL HOSPITAL, April

Lara stood silently at the bed of a 9-year-old girl who had died of internal injuries sustained in a car accident. The car had crashed because the girl’s parents had been fighting in the front seat. In his rage, the father had swerved the steering wheel. Now the father, uninjured, was in the hallway yelling at the trauma team, “You killed my daughter!” The mother was being treated for shock.

Lara could not bring herself to leave the dead girl’s bedside. From the outside, it didn’t appear as if anything was wrong with the girl. She looked like a doll. She looked like she was sleeping peacefully. She could have been friends with Lara’s daughter. For the first time in her nursing career, Lara wept openly at the hospital, despite the bustle in the corridor, the other needy patients, and the footsteps that tapped into the room behind her.

An arm wrapped around her waist. Lara looked up. Brianne, a longtime ER nurse, embraced her. An elementary school nurse on her off days, Brianne was crying, too. Nurses mostly didn’t afford themselves the time to cry; they forced themselves to go on with their day. Lara believed that South General nurses were more “honest” about their emotions than nurses at other hospitals where she had worked. Lara felt they were “more real, more vulnerable, they let themselves feel the moment with colleagues and patients’ families. We let them know that we’re sad along with them.” Lara had seen South General nurses get on their knees with grief-stricken family members to pray with them.

From then on, Lara asked to work with Brianne whenever she had the chance. She got to know her as a good nurse and a good person. She watched the comforting way Brianne interacted with patients and families and she tried to emulate her. “I just felt closer to her after that. She’s a genuine person who makes people feel better just by speaking with them, and I want to learn how to have that quality, too,” Lara said.

After the 9-year-old’s death, the trauma team could have used the Relationship-Based Care committee’s debriefing room—the calm space Lara had wanted to set up for staff members to catch their breath after traumas—but it still didn’t exist. The committee hadn’t met in months. Lara thought she knew why. Originally, management had promised the committee that they would find coverage for the members to attend meetings. But the administrators didn’t do so for the last few meetings, effectively canceling them. Even the huddles had dissolved after a couple of weeks because only Lara, Rose, and Holly attempted to gather the group when they were on duty.

Without meetings, the committee couldn’t get anything done. The administrators also refused to provide any resources for the debriefing room. Now that the managers had essentially squashed the idea, Lara was out $50 for the paint she had purchased.

One day, Lara was in the resuscitation room, where nurses sent the sickest patients or performed CPR. Five other nurses, all African American, walked in, including Makayla. Makayla was obsessive about bringing her own cleaning products to the ER to make sure her area was clean, although outside cleaning products were not permitted in the hospital. Nurses knew when they were in Makayla’s assigned zone because they were knocked sideways by the overpowering smell of bleach. Apparently, someone had complained, because Makayla told the other four nurses, “And one of our latte nurses felt the need to write me up that I had wiped down the area to make sure it was clean.” The other nurses clucked sympathetically.

For the moment, Lara didn’t say anything because she was outnumbered. There were only three white nurses left in the ER. When the black nurses left, Lara called Makayla back. “Makayla, I have to talk to you,” Lara said, speaking slowly to think through how to avoid putting Makayla on the defensive. “I respect you as a nurse and I know that you work hard. But I have to tell you, your comment about latte coworkers is racist. It wasn’t cool and I was sitting right here. I’m surprised to hear a comment like that coming from you.”

Makayla balked. “Oh no no, oh my gosh, no. I call people my mocha sisters and my latte sisters, but it has nothing to do with color!”

Nevertheless, for the next month, Makayla went out of her way to be nice to Lara. Normally, Makayla was the type of nurse who shopped online while other nurses ran around taking care of patients. Now she leaped up to help Lara, greeting her enthusiastically. Lara wasn’t going to waste energy resenting Makayla, so she let the incident slide.

•   •   •

Lara was giving report on the phone when she heard one nurse say to another, “Your girl’s marked off the schedule permanently.”

“That bitch is not my girl,” the other nurse replied.

Lara put her hand over the mouthpiece. “Hey, you guys, you shouldn’t gossip without me! Hold on!”

After Lara hung up, they told her what had happened. The day before, Fatima had been in other nurses’ rooms again, hovering around patients. To the other nurses, her behavior was simply annoying. To Lara, this was an obvious sign of an addict; she was hopping from room to room in search of narcs. One of the nurses Fatima tried to “help” happened to be Ursula, who notoriously preferred to work alone, which Fatima, a night shift nurse, wouldn’t have known.

Fatima saw an order for Dilaudid and took the medication from the med room. She charted that she gave the patient the medication, then apparently put it in her pocket.

Two hours later, the patient was still rolling around in pain. “Did anyone give you pain medication yet?” Ursula asked. “I see it was ordered.”

“No one’s been in here yet,” the patient said.

Ursula looked up the patient’s file and saw that someone had taken out Dilaudid under the patient’s name. She rounded up the charge nurse and the nursing supervisor and they pulled Fatima into an office. They told her their concerns.

“No, no, I was just helping medicate the patient,” Fatima said.

“Did you medicate the patient?” the supervisor asked.

Fatima tried to evade the inquiry.

“You need to answer this question: Did you give that patient the pain medication that you took out under his name?”

Again, Fatima gave a nonanswer.

“We believe you are taking narcotics. This has been a concern for a while. We need a urine sample.”

“No,” Fatima said, changing tactics. “I have the pain medication right here! I just didn’t have the chance to give it yet.” Ostensibly, she went to pull the patient’s vial from her pocket. Lara wondered later if Fatima had been so nervous that she didn’t think about what she was doing. The average Dilaudid dose was 0.5 milligram to 1 milligram. Fatima pulled out three 2-milligram vials.

“We’re going to have to ask you to leave if you won’t give a urine sample.”

Fatima wouldn’t provide the sample. She quit on the spot.

After the nurses told Lara the story, Lara tried to refocus their slant so that the narrative wasn’t about Fatima’s character. The South General nurses didn’t know about Lara’s own addiction. “Wow, she’s got a horrible disease,” Lara told them. “I hope she’s going to be okay. I’m going to say a prayer for her because I’d hate for her to overdose.”

Her coworkers were more empathetic toward Fatima than Lara had expected. “Drug addiction is more rampant than people would like to admit, and everyone knows it,” Lara theorized. “It’s not like ‘Oh my God, what a shock.’ It happens a lot.”

Lara had mixed feelings about Fatima getting caught. She felt bad that she had not gotten through to Fatima in time. But she also was relieved. “When I got caught, because I was so scared, there was a weird sense of relief,” she said. “So I’m relieved for her, too. She can move forward.”

The same week, Nicola, a younger nurse, approached Lara for advice. She had been cited for drunk driving over the weekend. Lara supposed that a mutual friend must have told Nicola that Lara didn’t drink. “I don’t know what to do,” Nicola said. “I don’t want to drink anymore, but I see things here and they’re sad. I go home and I don’t know how else to deal with the sad things or the frustration when people are mean at work. I drink to forget about the day.”

“That’s why I don’t drink,” Lara said. “I did the same thing. I didn’t just have a beer. I ordered double vodka sodas to forget stuff. But it didn’t really work, and then more stuff would pile on. So I just stopped. Do you want me to help find you a sponsor?”

“Nah, I’ll try to stop by myself first,” Nicola said.

Actually, Lara had been tempted to drink lately. Now that she was truly on her own, her worries overpowered her. It had been harder than usual to stay clean this season, because she’d paused her college classes, which had been one of her distractions. Without John at home, classes and childcare were prohibitively expensive. Trying to work out her frustrations at the gym wasn’t enough. “I’ve been in such a funk lately that I’m thinking being dead would be better than this,” Lara admitted. “I feel like I don’t have enough outlets for my fears. And I’m so tired. It pops in my head, If you drank or got high tonight it would be okay, just for tonight. So I’m sort of on watch.”

Lara still didn’t feel like herself at work; her personal issues had eroded even her confidence as a nurse. Often she came to the ER hoping she wasn’t assigned to seriously sick patients because she wasn’t sure that she would be able to think clearly enough to help. But sick patients always came in anyway, and, despite her misgivings, Lara found that “I don’t have time to be up in my head feeling sorry for myself, because people are sick and they need my attention.”

The patients at South General reminded her that her situation could be worse. One day, she spent three hours entertaining a toddler while his mother was evaluated. The patient had confronted her husband about his girlfriend and he had responded by choking her, hitting her, and kicking her pregnant belly. After the evaluation, the woman returned home and did not press charges.

Lara’s coworkers continued to create last-minute openings, using her as a floater to cover for nurses during lunch, or assigning her as an extra trauma nurse. Some of the other nurses confided to her that when they got divorced, they coped by working long hours, too. “We’re going to see more of you here,” one of the women told her. It was nice to know that her colleagues had her back. Lara regularly volunteered to work twelve-hour shifts on three consecutive days.

On the nights that she cried herself to sleep because she felt like “a horrible mom” for missing so much of her children’s lives, she reminded herself repeatedly that she was doing what was best for them. “I’m going to meetings to get mentally focused. I’m going to work to pay the bills and to cover their health insurance,” she told herself. “This is making me a better person so that I can be the best mom for them.”

The Code of Silence

Lara was an outstanding nurse who recognized that Fatima had an addiction. Her own troubles aside, why didn’t she act sooner to try to save her colleague from what has been called “one of the most devastating diseases in the nursing profession”?

Many nurses speak about a “code of silence,” an implicit vow of loyalty and protection that includes a reluctance to intervene when a fellow nurse’s job or reputation may be at stake. When they observe incompetence or suspicious behavior, some nurses might look the other way if a coworker is generally skilled or if they sympathize with her professional stresses or difficulties at home. This “don’t talk rule,” as it has been called, is akin to “What happens in the unit stays in the unit.” According to materials from a nurse home-study program, nurses “bend rules or . . . may not report other nurses for fear of being perceived as snitches or labeled as whistle-blowers. These nurses may be concerned about retribution for reporting, such as having their own work scrutinized and criticized. Some nurses do not want to become involved because confronting someone who may become angry, deny the problem, or plead for another chance can be difficult.” Lara hesitated for all of these reasons.

If they report a nurse for substance abuse, nurses worry that their colleague will lose her job or her license and/or be arrested. The public, as well as fellow healthcare providers, can be quick to stigmatize substance-impaired nurses, perhaps more readily than they condemn people in other fields. As the home-study material explained, “Society, in general, views nurses as angels of mercy; nurturers par excellence; or the lily-white, starched presence of yesterday’s movies. Being placed on such a pedestal has its consequences when a nurse becomes a ‘fallen angel.’ Society and other healthcare professionals are quick to demonize this fallen angel as a ‘bad person’ who now steals our grandmother’s pain pills.”

It’s easy to see why the stigma persists: Disturbing examples abound in the news. In several states, nurses (and other healthcare providers) have been caught stealing drugs from hospitals or nursing homes for personal use. In Texas, an army medical center nurse used his own syringe to steal fentanyl, a painkiller, from vials that the center then used for other patients; he infected at least sixteen patients with hepatitis C. Nurses across the world have stolen narcotics and replaced or diluted them with tap water or saline solution, leading patients to receive saline instead of pain medication during surgery. A nurse at a nursing home in England was charged with killing a patient and taking her medication. The nurse became hooked on painkillers when she was prescribed medication for her migraines.

Because of a lack of self-reporting, it is difficult to pinpoint a reliable statistic for the number of nurses who are chemically dependent. The American Nurses Association estimates that 6 to 8 percent of nurses currently are impaired at work because of drug or alcohol abuse. While nurses abuse alcohol at the same rate as the general population, studies have found that addictions to prescription drugs, specifically, are between five and 100 times greater among nurses, a wide-ranging estimate.

What’s more surprising than the number of drug-addicted nurses is their quality of work. Research shows that often the nurses who become addicted are skilled, achieving, respected medical professionals—the admired super-nurses, not the inconsistent employees, suspect from the start because of checkered pasts.

A Journal of PeriAnesthesia Nursing study reported that 67 percent of nurse anesthesia students with substance abuse problems were in the top third of their graduating class, while less than 5 percent were in the bottom third. Another small study described chemically dependent male nurse subjects as “intelligent, calm, and controlling individuals who were considered competent leaders in the clinical setting and whose peers enjoyed working with them.” The study subjects were highly ranked nursing school students, all of whom considered themselves perfectionists and received excellent evaluations from their supervisors.

Smart, driven nurses may be more likely to become addicted to prescription medications because they “believe they have the knowledge and ability to control the use of dangerous drugs when, in fact, they do not,” the Journal of PeriAnesthesia Nursing researchers guessed. They may be less inclined to admit to themselves or others that they are addicted because they don’t believe they can fall that far. It took Lara months to realize that her stomachaches were related to an addiction; she might have made the connection immediately if she were assessing a patient instead of herself.

Like Lara, nurses are much more likely than the general public to have a family member who has struggled with alcoholism. People who have cared for an afflicted relative may be inspired to enter nursing because it is a helping profession. But this background may also be a factor in the odds of becoming addicted. If the disease runs in their family, they may be more susceptible. And if they think of themselves as someone who helps others, rather than someone who should ask for help, they might not recognize their own downward spirals in time. ER, OR, PACU, and ICU nurses, who might see unexpected deaths and tragedies more frequently, experience substance abuse in larger numbers than other nurses. As in Lara’s case, the drugs can both energize them and seemingly help them to cope with these traumas.

Certified registered nurse anesthetists (CRNAs) may be even more vulnerable than other nurses to chemical dependency. Experts estimate that the addiction rate among CRNAs and anesthesiologists “has reached staggering levels,” at more than 15 percent. Nurse anesthetists are at a higher risk for substance use disorders because “they’re playing with rocket fuel,” said CRNA Art Zwerling, an American Association of Nurse Anesthetists (AANA) peer assistance advisor. “The stakes go way up because folks are working with and diverting drugs that are much more powerful.” People can become hooked on fentanyl, which is eighty times more potent than morphine, from just one exposure. “It’s also that we work in isolation and the production pressure in anesthesia is horrendously escalated,” Zwerling said. “People have bad times on call, remember how comfortable their patient looked when they were given fentanyl, and see that as a potential stress reducer.”

Jan Stewart, a CRNA for twenty-eight years, was the president of AANA and a nationally recognized lecturer. The AANA called her “a dedicated professional whose expertise knew no bounds and who was committed to the mission of providing high-quality, compassionate care to all patients. She was acclaimed by many as a leader among leaders and a friend to all.” Following back pain so intense that she needed surgery, Stewart eventually became addicted to painkillers. She died at age 50 of an overdose of sufentanil, an opioid hundreds of times more powerful than morphine. That’s how many nurses, like anyone, become addicted: They have a legitimate prescription whose effects become irresistible.

Perhaps the most persuasive reason that CRNAs and critical care nurses are more prone to addiction is the same reason that nurses are more vulnerable than the public. They have easier access to the drugs. It seems intuitive but it’s worth mentioning: Studies show that nurses who have easier access to these substances abuse them more often. (Doctors’ substance abuse is also linked to their ease of access as well as the frequency with which they prescribe the drugs.) The effect of access is twofold. The drugs are simple to get, and the nurses’ familiarity with them instills a confidence and a “pharmacological optimism” that they can self-medicate without becoming addicted. They believe they are more invulnerable than the general population.

Actually, the opposite may be true. Medical professionals tend to get sicker than the average drug addict because the medications they have access to are more powerful and habit-forming than street drugs.

How are they able to steal from hospitals, nursing homes, hospice centers, and other workplaces? Lara’s initial strategy of taking only drugs that were to be wasted is an inconspicuous method. Other nurses take patients’ doses for themselves and chart that they gave it to the patients, or they document, for example, that they gave a patient two pills when they actually gave only one. They might sign out drugs for people who have already been transferred or discharged from the unit. They can steal prescription pads and forge prescriptions, take samples from supply closets, back-date medical records, write verbal orders that a doctor didn’t give, or take advantage when coworkers forget to log off drug-dispensing machines. Or they get creative. A nursing home RN in Florida ate the gel from two narcotic patches meant to relieve pain for a burn victim and a patient with muscular dystrophy. He gave the patients placebos.

When the addicts aren’t obvious, like Fatima sticking her hand into a sharps box, their behavior may go unnoticed for months to years. Because these are often highly skilled nurses, they are, for a time, able to work competently under the influence. “Often, it’s our best people,” Laurie Badzek, director of the ANA’s Center for Ethics and Human Rights, has said. “They have such good clinical skills that they can be impaired and still be functioning at a good level. But eventually, it catches up [with] them.”

Even when managers do suspect drug abuse, they don’t necessarily act immediately. Hospital administrators might wait because they want to catch the employee red-handed, assemble a file’s worth of evidence, or avoid reacting in a way that might draw public attention. Many employers don’t provide candid references for employees (even fired employees) because they are afraid of lawsuits or desperate to shoo them out of the workplace. Addicted nurses can then job-hop, expanding their access to the narcotics they crave.

Coworkers who observe suspicious behavior might not be certain what they saw, what it means, or what to do about it. As of 2013, nurse anesthesia programs are required to include chemical dependency content in their curricula. Other nursing schools “should incorporate prevention and education,” according to the American Association of Colleges of Nursing, but the AACN doesn’t monitor whether schools comply. Students become nurses who may not be adequately educated about the dangers and prevalence of chemical dependency, how to recognize when colleagues might be impaired, and how to help them. This lack of awareness “enables an abusing nurse to continue and prevents colleagues from documenting and reporting the suspicion,” nurse Debra Dunn wrote in an article for the Association of PeriOperative Registered Nurses. “This passive environment condones the code of silence. Embedded in nursing culture is the practice of covering up for a colleague with a perceived problem, which can actually exacerbate the original problem rather than help the individual concerned. . . . Usually, by the time a nurse is caught and confronted, most of the people in the unit knew there was a problem.”

Nurse addicts may hide their secret for as long as possible, because they don’t realize they can get help without losing their license or they keep believing they can quit without assistance. They often continue to steal medications until they get caught. When they are caught, the consequences can be steep: License suspension is the most common result, and civil and criminal penalties are possible. Prosecutors can demand that a nurse not only surrender her license, but also that she never again work in healthcare. If a nurse turns herself in, however, she has a chance to save her livelihood. Nursing boards are usually more interested in helping nurses to rehabilitate and return to the workplace than juries, who are more inclined to kick nurses out of the field.

Eventually, most nurse addicts will have two choices: get help or get caught. “The good news is if the nurse enters treatment, they’re covered by the American Disabilities Act, so that helps to protect their license,” said Al Rundio, president of the International Nurses Society on Addictions and a practicing nurse himself. “But if they get confronted by the DEA prior to getting in treatment, they’re not covered by ADA so their license is more at risk. The longer you let it go on, the bigger the problem becomes.”

Certainly the focus on reparative programs rather than punitive measures is not without controversy. A relapse could endanger an impaired nurse, her patients, and her workplace. And not every rehabilitative program succeeds. A Los Angeles Times and ProPublica investigation revealed that participants in a California nursing board program continued to work while impaired, including more than eighty nurses whom the board deemed “public safety threats.” Even when the board expelled nurses from the program, the reporters found, “The board takes a median 15 months to file a public accusation—the first warning to potential employers and patients of a nurse’s troubles. It takes 10 more months to impose discipline.” California eventually instituted stricter rules, and ended an anonymous rehabilitative program for doctors following complaints that doctors in treatment were bungling surgeries.

While all fifty states have treatment programs that protect a doctor’s license, only forty-one have nondisciplinary alternative programs for nurses. Nurses with substance abuse issues have fewer resources than doctors, report more problems following treatment, and receive more frequent and more severe professional sanctions. The Journal of Advanced Nursing reported, “The rate at which nurses were placed on probation was not only higher than physicians prior to treatment, but was also disproportionately higher than doctors after treatment. . . . Therefore, the group who can least afford to miss work appears to be most likely to be reprimanded and may be least likely to seek costly legal representation.”

Despite high numbers of addicted nurses, fewer than 1.5 percent of nurses are enrolled in substance abuse monitoring programs. Massachusetts, for example, has approximately 140,000 nurses, about 200 of whom are enrolled in the state program at any given time. “If you go by national statistics for drug abuse, you’re talking eight to ten percent,” said Douglas McLellan, RN coordinator for Massachusetts’ Substance Abuse Rehabilitation Program. “If you apply those numbers to nurses in the state, there should be twelve to fifteen thousand nurses in our program. God only knows what they’re doing.”

Nurses can nudge coworkers to self-report by compassionately mentioning the topic. “The best recommendation is to know how to identify an impaired colleague and get them safely into treatment. Once the brain is hijacked by addiction, it’s deeply in denial. Usually, an individual will not seek help. It’s up to others,” said Julie Rice, who manages the AANA Health, Wellness, and Peer Assistance Programs. (See here, for additional resources for nurses with substance abuse issues.)

Loyalty is admirable, and one of the bonds that make this subculture so strong. The sisterhood is more powerful, though, when nurses can ask their peers for aid, and when colleagues, unbidden, can reach out to help. Overlooking an addicted nurse’s transgressions protects neither the nurse nor her patients. The ANA has stated that “it is every nurse’s responsibility to acknowledge the needs of an impaired nurse and to help him or her regain full professional capacities.”

In fact, experts warn that a nurse is legally responsible to turn in an impaired coworker; if a patient suffers, some states can bring charges against the nurse who didn’t report her colleague. Reporting an impaired colleague can save her life—and her patients. There should be no stigma when, as one nursing administration journal phrased it, “the nurse becomes [the] nursed.”

Nurses’ patient advocacy can extend toward their fellow nurses when it is clear they need treatment. Getting them help may break the “don’t talk rule,” but ultimately, the code of ethics outweighs the code of silence.