Prescription Misuse and Other Risk Factors for Substance Use Disorders among Student Nurses: Results of a Pilot Test Using the Shunt Self-survey for Nurses

Substance use disorders (SUDs) are chronic, progressive conditions which usually develop over time. Most nurses with SUDs report substance use began before or during nursing school. As nursing students are vulnerable to SUDs involving prescription drugs, it seems plausible that student nurses may be able to make modifications in their behavior and circumstances if they had a tool by which to measure their risk. The aim of this study was to identify acceptability and feasibility of a brief self-survey which identifies at-risk behaviors for SUDs in nurses that could also be used by student nurses. A pilot test of 26 senior baccalaureate nursing students found over 11% reported past misuse of medications and over 7% reported a negative consequence due to alcohol, drug or medication use. Further studies are needed to construct validity, reliability and to test internal consistency of this tool, but given the minimal investment of time, low cost of administration, and the potential benefits of early detection of risk associated with SUDs in nursing students, knowledge as well as incentive to conduct ongoing self-appraisals by all students nurses seems warranted. INTRODUCTION Substance use disorders (SUDs) have long been described as chronic and progressive conditions. Earlier initiation of substance use has been identified as a risk factor which increases the likelihood of more serious problems with substance abuse and addiction (NIDA, 2007). Research has demonstrated a strong correlation between the occurrence of SUDs and genetics (Kreek, 2004). Almost one in five 12 to 17 year olds surveyed in 2008 reported that they could obtain prescription drugs in order to get high in an hour’s time, with more than a third noting that they could procure these substances within a day (National Center on Addiction & Substance Abuse at Columbia, 2009). A significant portion of middle and high school students are using prescription drugs for recreational, non-medical purposes, with the incidence of any use of a prescription drug for non-medical purposes among 12 graders reported to be 15.4% in 2008 (Johnston, 2008). Most studies have cited the lifetime incidence of SUDs in nursing professionals to be between 10% and 20% (Griffith, 1999). Nurses have been noted to be at significantly higher risk of addiction to mood-altering prescription substances compared to the non-nurse population (Trinkoff, 2000). Research has demonstrated that substance abuse among nurses often begins before or during nursing school (Coleman, 1997) with prescription drug use particularly common among student nurses (Kornegay, 2004) and depression noted as one of the most frequent reasons for nursing student’s use of substances (Ahmadi, 2004). Other psychodynamic factors in individuals with SUDs, such as lack of meaningful relationships, low self-esteem and lack of self-regard, have also been observed (Smith-DiJulio, 2006). In 2007, the University of Memphis School of Nursing (UMSN) developed a more uniform and comprehensive policy regarding substance use and/or abuse in nursing students after four had been identified with such issues over a two year period (Monroe, 2009). Given the present trajectory of prescription misuse among youth and higher rates of prescription abuse in nurses than the general public, it seems nursing schools may experience an increasing frequency of issues with substance use and abuse among nursing students than in past decades. Additionally, an increased number of student nurses may remain just beneath the threshold of detection for SUDs in nursing programs, only to come to the attention of State Boards of Nursing, alternative to discipline programs and employers after licensure. Screening for SUDs in all patient populations aged 12 and older has been recommended in primary care settings and emergency departments for some time (Institute of Medicine, 1994). Such initiatives have been increasingly encouraged as a standard practice for healthcare providers so that earlier detection can lead to timely intervention and improved outcomes (Osterman, 2009; NYC Dept. of Health & Mental Hygiene, 2009; Murphy, 2009). Additionally there has been a call for more education regarding the issue of SUDs within the nursing profession and schools of nursing (Dunn, 2005). The potential consequences to substance abusing student nurses are quite steep, including deterioration of physical and emotional health, expulsion from school, inability to obtain professional licensure, criminal prosecution, and loss of reputation and self-esteem. While substance abuse in nurses poses a risk of fatality to the nurse and a threat to patient safety (Smith, 1998), the threat to student nurses is at least as great due to the co-morbidity of depression (Ahmadi, 2003). Shame related to expulsion from nursing school poses a risk of overdose and suicide, particularly if student nurses do not receive treatment (Monroe, 2009). Nurses and those about to enter nursing practice are held to exemplary standards of practice and held accountable for identifying any situations which indicate they are not able to perform nursing duties safely. They are also held to standards of moral conduct above what is expected from non-licensed individuals. Nurses are undoubtedly well-trained and experienced in the process of assessing patients and familiar with regular personal self-screening practices, such as self-breast exams or testicular exams. Though today’s nursing students may not yet have as finely-honed skills and years of experience as licensed nurses, their schooling provides cutting edge evidence based practice which includes familiarity with multiple tools of assessment for various physical and psychiatric disorders, including SUDs. As SUDs usually develop over a period of time and are often accompanied by a constellation of characteristic behaviors and circumstances that are sometimes detectable before extreme consequences occur (Mynatt, 1996), it seems plausible that student nurses may be able to selfassess an escalating trend towards behaviors and circumstances which often occur in nurses with SUDs. If student nurses can recognize increased characteristics in themselves which tend to cooccur with SUDs, it is possible that some nursing students may be able to modify their behavior or circumstances and become alert to a possible need for enhanced support, or formal evaluation and treatment, prior to progression of SUDs and/or the development of their most dire sequelae. In an effort to test how student nurses would respond to a self-survey developed to assess risk factors for SUDs specific to nursing professionals, a small sample of senior baccalaureate nursing students were given a questionnaire containing the ten items on the SHUNT Self-Survey For Nurses described in the book “Unbecoming A Nurse” (Scimeca, 2008). The ten traits identified on the self-survey were extracted from general research studies regarding SUDs, studies specific to nurses with such disorders and direct observation of nurses who voluntarily surrendered their license to practice nursing due to SUDs. Lack of meaningful relationships has been observed in those with SUDs (Smith-DiJulio, 2006). Evidence suggests that loneliness is a risk factor in the development of SUDs and that the prevention of loneliness may be helpful in the prevention and treatment of SUDs (Page 1990; Page, 1991; Nerviano, 1976). For these reasons, social withdrawal or self-isolative behavior was identified as a risk factor on the original self-survey and was included on the questionnaire for nursing students. Self-care behaviors have been noted to be beneath societal norms in many individuals with SUDs (Moore, 2001). One of the most striking observations of those with advanced progression of SUDs is a disheveled appearance. Common psychodynamic factors such as low self-esteem and lack of self-regard have also been observed in those with SUDs (Smith-DiJulio, 2006). Lack of self-regard may negatively impact an individual’s attention to self-care practices. As the hallmark of addiction is an uncontrollable urge to use substances, it is likely that self-care would be deferred in favor of satisfying overwhelming cravings. Self-care behaviors beneath societal, professional or the nurse’s own standards was an item included on the original self-survey for nurses. For this pilot test of student nurses the original wording was changed from “the nurse’s own standards” to “your standards” to more accurately reflect the status of the students. A family history of SUDs is a risk indicator as research has demonstrated a strong correlation between genetics and the occurrence of SUDs (Kreek, 2004). Because history of SUDs in the immediate family is highly predictive of a genetic predisposition to SUDs, history of chemical dependency in the nurse’s immediate family was included in the original self-survey for nurses. The questionnaire given to the students was amended from “nurse’s immediate family” to “your immediate family.” SUDs have long been described as chronic and progressive conditions. Earlier initiation of substance use has been identified as a risk factor which increases the likelihood of more serious problems with ongoing substance use, abuse and addiction (NIDA, 2007). As one of the best indicators of a future problem with SUDs is a past negative consequence related to alcohol, drug or prescription medication use, history of negative consequences related to the nurse’s substance use was included as a risk factor. The questionnaire provided to nursing students omitted the word “nurse’s” used in the original self-survey so that the item stated “History of negative consequence due to past substance use.” Co-morbidity of mood and other psychiatric disorders in clients with SUDs has been well documented (NIDA, 1999). Major depressive disorder and bipolar disorder have been noted as the most significant indicators for relapse in nurses in recovery from SUDs (Fogger, 2009). Chronic physical pain is frequently present in nurses with SUDs (Dunn, 2005; Maher-Bryson, 2007). For these reasons, untreated or unremitting emotional or physical pain was noted as a risk factor measured on the original self-survey and remained intact for the pilot test of student nurses. Nurses have been noted to be at significantly higher risk of addiction to mood-altering prescription substances compared to the non-nurse population (Trinkoff, 2000). As using medication for a reason it was not intended or in a manner not recommended are both examples of medication misuse and such misuse is a risk, this factor was included in the original selfsurvey and on the student questionnaire. Overwork has been noted as a frequent occurrence in nurses with SUDs, particularly those who obtain their substance(s) from the workplace. Nurses who routinely work far beyond the equivalent of full-time hours required for their position naturally have less time available to recuperate from stressors related to work. Maintenance of optimal health practices such as relaxation, exercise and other endeavors which support and fortify emotional and physical health are often negatively impacted by excessive work (Dunn, 2005). Overtime is strictly curtailed by most monitoring programs when nurses initially return to practice after restoration of their license related to SUDs to minimize this risk. To identify the risk inherent in overwork, nursing practice routinely in excess of 55 hours per week was noted on the original self-survey. To more accurately reflect the student’s situation, the phrase “nursing practice” was amended to “working.” Nursing duties which include frequent access to controlled substances has been noted as a risk factor in the development of SUDs involving controlled substances (Dunn, 2005; Trinkoff, 2000). While access does not pose a problem for the vast majority of nurses, it does seem to merit inclusion on any self-appraisal of a nursing professional’s risk for SUDs. The phrase “nursing duties” was changed to “employment” on the student questionnaire. Navigation through major transitional stages has been found to be extremely difficult for those with SUDs (Sinha, 2001). As transitional stages are universal life experiences and present special challenges to those susceptible to SUDs, a transitional period requiring major adjustment in the past year was added to the original self-survey and was also included on the student selfsurvey. Clients with SUDs often possess less than adequate coping skills and tend to respond to stress by using or abusing substances (Gelfand, 1990; Naegle, 1988). A history of past trauma has been noted in some research regarding nurses with SUDs (Ponech, 2000). Use of substances as a coping strategy to deal with emotional discomfort often precipitates ongoing difficulties in family life and the workplace (Coleman, 1997). Continued substance use does not resolve such issues and may lead to increased turmoil and conflict. For this reason, turmoil or tragedy with unresolved conflict was identified as the tenth risk factor on the original self-survey and remained intact on the student questionnaire. The acronym SHUNT was selected for the original self-survey as each of the five letters represents a letter which corresponds to the first letter of the first word of two of the ten items on the survey. The acronym also seemed fitting as the aim of the self-survey is to shunt nurses away from behaviors and circumstances which increase their risk of SUDs. Social withdrawal or self-isolative behavior Self-care behaviors beneath societal, professional or the nurse’s own standards History of chemical dependency in the nurse’s immediate family History of negative consequences related to the nurse’s substance use Untreated or unremitting emotional or physical pain Using medication for a reason it was not intended or a manner not recommended Nursing practice routinely in excess of 55 hours per week Nursing duties include frequent access to controlled substances Transitional period requiring major adjustment within the past year Turmoil or tragedy with unresolved conflict The purpose of this study was to (a) determine the self-survey score range of a small sample of student nurses; (b) identify what percentage of students would report they were in recovery from SUDs; and (c) determine if scores of student nurses in recovery differ from student nurses who did not report a problem with substances and that no one had expressed concern regarding their substance use.