good work environments . . . “throughout the world.” Linda H. Aiken et al., “Importance of Work Environments on Hospital Outcomes in Nine Countries,” International Journal for Quality in Healthcare (August 2011).

Higher staffing of registered nurses . . . assigned eight. Linda H. Aiken et al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” Journal of the American Medical Association (2002).

failure-to-rescue rates drop . . . to die See, for example, Arminee Kazanjian et al., “Effect of the Hospital Nursing Environment on Patient Mortality: A Systematic Review,” Journal of Health Services Research and Policy (April 2005); Linda H. Aiken, “Investments in Nursing Save Lives,” Center for Health Outcomes and Policy Research. A PowerPoint presentation supported by National Institute of Nursing Research; Ann Kutney-Lee et al.

readmitted to the hospital. See, for example, Jonathan Gruber and Samuel L. Kleiner, “Do Strikes Kill? Evidence from New York State,” National Bureau Of Economic Research Working Paper Series (March 2010).

stay is shorter . . . error is lower. See, for example, Rebecca Hendren, “Nurse Staffing Costs Must Be Weighed Against Cost of Errors,” HealthLeaders Media, August 30, 2011.

the fewer the nurses, the higher . . . Jeannette Rogowski et al., “Nurse Staffing and NICU Infection Rates,” JAMA Pediatrics (May 2013).

hospitals could earn . . . and fewer tests. See, for example, Linda H. Aiken, “Investments in Nursing . . .”

in poor nurse working environments . . . saved every year. Linda H. Aiken, “Investments in Nursing . . .” In correspondence with the author, Aiken, a leading nurse researcher, clarified that “frequently” is defined as “once a month or more often.”

“the single most critical . . .” “HCAHPS: Hardwiring Your Hospital for Pay-for-Performance Success,” Studer Group webinar, 2011.

check in with patients every hour Ibid.

“The Most Bang for Your Buck” Ibid.

“to promote higher quality . . .” Federal Register, Department of Health and Human Services 76, no. 160, August 18, 2011.

“building a culture of healthcare excellence” Disneyinstitute.com.

Chapter 7

“I will abstain . . .” Florence Nightingale Pledge at the American Nurses Association: http://nursingworld.org.

“It’s insanely easy . . .” Interview.

“one of the most devastating . . .” See, for example, T. Monroe, “Addressing Substance Abuse Among Nursing Students: Development of a Prototype Alternative-to-Dismissal Policy,” Journal of Nursing Education (May 2009).

“code of silence” Interviews; see also, for example, Debra Dunn, “Home Study Program: Substance Abuse Among Nurses—Defining the Issue.” AORN Journal (October 2005).

“don’t talk rule” Debra Dunn,

“bend rules or . . . can be difficult.” Ibid.

nurses worry that . . . Ibid.

quick to stigmatize . . . Ibid. See also “Substance Use Disorder in Nursing,” National Council of State Boards of Nursing, 2011.

“Society, in general . . . grandmother’s pain pills.” Ibid.

army medical center nurse . . . hepatitis C. Darren Meritz, “Former Nurse at Beaumont Army Medical Center Given 3½ Years,” El Paso Times, December 2, 2009.

Nurses across the world have stolen narcotics See, for example, Clair Weaver, “Nurse Stole Pills off Elderly,” Sunday Telegraph (Australia), August 10, 2008; Myra Philp, “Missing Drugs: 6 Nurses Axed; Staff Suspended in Morphine ‘Theft’ Probe,” Sun, August 17, 2009.

replaced or diluted it . . . during surgery See, for example, “Fentanyl Replaced With Saline Solution During Surgical Procedures,” US Fed News, November 29, 2006; Pat Grossmith, “Indictment: Nurse Diluted Drugs,” Union Leader (Manchester, NH), July 18, 2008; Roxanna Hegeman, “Kansas Nurse Gets 3 Years in Drug Tampering Case,” Capital-Journal, February 3, 2012; “Nurse gets 3 years for drug tampering,” Capital-Journal, February 25, 2012; “Woman Sentenced to Probation for Stealing Painkillers,” August 6, 2005; “Pain Medication Thefts: Nurse’s Drug Problem Was Recorded,” Daily Camera (Boulder, CO), July 9, 2009.

nurse at a nursing home . . . for her migraines. “Former care home worker is struck off nursing register,” Wells Journal, April 28, 2011. She was accused of killing other patients, but was cleared. See “Nurse accused of murdering two of the elderly residents she was stealing drugs from.” Wells Journal, January 28, 2010.

6 to 8 percent of nurses Author correspondence with an ANA representative. Also see, for example, Cynthia Clark and Judy Farnsworth,“Program for Recovering Nurses: An Evaluation,” Medsurg Nursing (August 2006). See also Patricia Welch Dittman, “Male Nurses and Chemical Dependency: Masterminding the Nursing Environment,” Nursing Administration Quarterly (October–December 2008); Madeline Naegle, “Nurses and Matters of Substance,” NSNA Imprint (November–December 2006).

same rate as the general population See, for example, Thomas Zambito, “High Anxiety in Hospitals: Nurses in Drugs, Drink Crisis,” Daily News (NY), March 14, 2004; “What To Do When Confronting an Impaired Colleague,” Medical Ethics Advisor, June 1, 2005.

between five and 100 times greater. T. Monroe, “Addressing Substance Abuse Among Nursing Students: Development of a Prototype Alternative-to-Dismissal Policy,” Journal of Nursing Education, May 2009.

skilled, achieving, respected See, for example, Matthew F. Shaw et al., “Physicians and Nurses with Substance Use Disorders,” Journal of Advanced Nursing 47, no. 5; Jane Hedrick; Debra Dunn.

67 percent of nurse anesthesia students . . . the bottom third. Jane Hedrick and Stephanie Luck, “The Alarming Trend of Substance Abuse in Anesthesia Providers,” Journal of PeriAnesthesia Nursing (October 2004).

“intelligent, calm”. . . from their supervisors. Patricia Welch Dittman.

“believe they have the knowledge” Jane Hedrick and Stephanie Luck.

are much more likely . . . downward spirals in time. See, for example, Debra Dunn.

ER, OR, PACU . . . cope with these traumas. Ibid. See also “Substance Use Disorder in Nursing.”

“who enjoy a high degree” http://www.aana.com/ceandeducation/becomeacrna/pages/default.aspx.

may be even more vulnerable . . . at more than 15 percent. Jane Hedrick and Stephanie Luck.

“they’re playing with rocket fuel . . .” Interview with Art Zwerling by Eaves. Some researchers have suggested that “exposure to trace quantities of these agents in the workplace sensitizes the reward pathways in the brain and promotes substance abuse.” Heather Hamza and E. O. Bryson, “The Drug Seeking Anesthesia Care Provider,” International Anesthesiology Clinics 49, no. 1 (2011).

Jan Stewart, a CRNA . . . a friend to all.” http://www.aana.com/resources2/health-wellness/Pages/Jan-Stewart-In-Memoriam.aspx.

back pain so intense . . . Sarah Ruth Gomes, Foreword, in Paula Davies Scimeca, Unbecoming a Nurse: Bypassing the Hidden Chemical Dependency Trap. Sea Meca, 2008.

died at age 50 . . . www.aana.com/resources2/health-wellness/Pages/Jan-Stewart-In-Memoriam.aspx.

opioid hundreds of times . . . See, for example, M. A. Clotz and M. C. Nahata, “Clinical Uses of Fentanyl, Sufentanil, and Alfentanil,” Clinical Pharmacology (August 1991).

That’s how many nurses . . . See, for example, Blythe Bernhard, “On Drugs, on Duty: Doctors, Nurses with Easy Access Can Be Vulnerable to Addiction.” St. Louis Post-Dispatch, March 26, 2008.