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.