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In nurses that abuse substances, are comprehensive drug diversion response programs

beneficial in supporting recovery?

EBP Project/Research

Casey Gatto

Seton Hill University

SNU 315 75 Research & Evidence-Based Practice

Carrie Slagle MSN/Ed, BSN, Phd

November 26th, 2022

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Introduction

Nurses are the heart and soul of the healthcare system. When a nurse is impaired or

unable to perform care it can be detrimental to the patient’s wellbeing. Nurses who abuse

substances cannot accurately make critical care decisions. Patients also do not get the

medications they need if a nurse is diverting or wasting medications for their personal usage.

This is why it is important to have detection programs in place so that nurses are able to

recognize signs of substance usage in their coworkers and peers. The clinical question that will

be looked at is: In nurses that abuse substances, are comprehensive drug diversion response

programs beneficial in supporting recovery? The therapy/intervention PICOT question format

was used to develop this clinical question as this question is assessing the detection programs

effectiveness in identifying nurses who may have substance use issues. This is an important topic

considering the growing prevalence of nurses who have been diagnosed with substance abuse

disorders. Recent studies have found that nurses were more likely to have positive toxicology

results for nearly all substances compared to the general public and they had a documented

increased risk of suicide (Handzel, 2022). The risk for suicide was due to the factors of stigma,

licensure, and limited access to treatment (Handzel, 2022). Finding an effective detection method

for which peers and coworkers can implement is the key to successfully supporting nurses in

their substance usage recovery. It has been noted that many nurses with substance abuse issues

will feel embarrassed to reach out, are in denial, or do not want to lose their position in the

workplace which could be the reason that treatment is delayed. This is why it is important for

nursing coworkers to be able to detect substance issues and properly intervene.

Background
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A substance abuse disorder is a substance issue which affects the lifestyle and mental

status of the individual's life. The history of the healthcare system and substance abuse issues

related to mental health is limited as individuals with substance abuse problems were sent to

psychiatric facilities or asylums. The first rehabilitation center specifically for substance abuse

was created in 1864 (American Addiction Centers Editorial Staff, 2022). This facility was called

the New York State Inebriate Asylum (American Addiction Centers Editorial Staff, 2022). A

major step in rehabilitation was founded in 1935 by Dr. Bob Smith and Bill Wilson called

Alcoholics Anonymous or AA (American Addiction Centers Editorial Staff, 2022). AA provides

a welcoming environment where individuals living with alcohol disorders/ issues could find

support (American Addiction Centers Editorial Staff, 2022). As related more specifically to the

nursing population, nurses are required and encouraged to attend programs like AA just as any

other civilian would. Many hospitals did not offer addiction services until the 1980’s when the

state legislature approved treatment for healthcare professionals (Nurses and addiction 2020).

Nurses go through more programs, monitoring, and testing than does the average civilian to

verify that they will maintain sobriety to be able to return to working as a safe nurse as is the

policy of the nursing leadership teams and the State Board of Nursing. As is relevant, each state

and facility has their own set of policies of which the nurse can return back to work. Nurses

develop substance usage issues due to the fact that nursing is very high stress especially

considering the nursing shortage. Burnout has been reported in 50% of nurses (Handzel, 2022).

A Nursing Times survey found that 63 percent of participating nurses experienced physical or

mental side effects of job-related stress (Nurses and addiction 2020). Another factor that puts

nurses at a higher risk for developing a drug dependency is that drugs are more easily accessible.
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There are detection programs set in place for nursing staff implemented in facilities around the

United States as directed by that specific state's Board of Nursing (BON).

An important detection program that can be implemented in the hospital is

comprehensive diversion response programs or CDRP’s. Drug diversion programs look at nurses

obtaining substances illegally while at work. This program provides an effective way to approach

identifying, intervening, and supporting healthcare workers with suspected substance abuse

issues. The Joint Commission and the American Association of Nurse Anesthetists emphasize

the importance of instituting CDRP’s in the healthcare setting (Stone et al., 2021). Most hospitals

use electronic medical records, automated dispensing cabinets, and internal controlled substance

audits to prevent substance diversion (Health Care's hidden epidemic). However, there is a lot

more that needs to be witnessed and that can’t be reported by technology. Nurses can

electronically waste a substance but they may not be actually wasting it but instead taking it for

personal use. This program will also provide education about how a nurse is able to identify

substance usage. Nursing coworkers will be able to notice signs of suspected nurses' using

substances. Strategies for this education can include competencies, guest speakers, awareness

campaigns, and continuing education opportunities (Stone et al., 2021). The intervention portion

of the program includes documenting and reporting what the nurse has observed from another

nurse's suspected substance usage.

Literature Review

The clinical question was answered by utilizing three online databases being WorldCat,

CINAHL, and MEDLINE on the Reeves library website. Nursing Journals and Websites have

also been used to get the proper perspective. Keywords that were used to find resources included

substance abuse, nurses, detection programs, signs and symptoms of substance abuse, healthcare
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providers, workplace, diversion, drug diversion, comprehensive diversion response program,

CDRP, and substance usage. The sources used were reliable as they were from less than five

years and were based in the United States. The location is important for this research because

policies can vary globally. Different policies and procedures are essential education for nurses in

different facilities and states. Because detection is the main key point in this research, the

research will not be looking into the types of substance usage. Looking into the different types of

substance usage will take away from the importance of noticing overall signs and reporting them

so treatment can begin as early as possible. Nurses are not responsible for having to know which

substance another nurse may be using but are responsible for reporting suspicion of another

nurse using a substance. Nursing leaders and higher ups will take care of the laboratory processes

that will determine what substance another nurse could be taking along with the treatment that

should be provided.

Comprehensive drug diversion programs were shown to be effective in early detection

and prevention among nurses with suspected substance usage (Fan, 2019; Karikari, 2022; Simon,

2019; Solvang, 2022; Tellson et al., 2022; Health Care’s hidden epidemic; Knight et al., 2022;

Perry & Vandenhouten, 2019; Nyhus, 2021; Porter, 2022). Comprehensive drug diversion

programs are encouraged to be implemented in all facilities by the Joint Commision (Stone et al.,

2021). Since the studies have deemed this program effective, the research will be looking more

closely at what exactly about this program makes it effective. Policies and Procedures are forever

changing. Most studies believe that the effectiveness of the program can be attributed to the early

prevention and detection by nursing staff (Fan, 2019; Karikari, 2022; Simon, 2019; Solvang,

2022; Tellson et al., 2022). Some studies suggested that data and technology were the prime

detection methods used in comprehensive drug diversion response programs (Health Care’s
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hidden epidemic; Knight et al., 2022; Perry & Vandenhouten, 2019). To clarify, nurses from

these studies were following policy procedures of wasting substances with proper documentation

but a new software was added to detect patterns of diversion and to help interpret findings. The

reason why technology is being looked at is because the nurse and leaders will have a concrete

idea of diversion. Observing another nurse can lead to subjective or biased findings; this was a

way to mitigate that error. Because of the documentation aspect of technology and the need for

the nursing staff to interpret the findings from the software, detection teams are still a necessary

factor in a comprehensive drug diversion response program. Two studies did not fit into either of

those categories because they talked more about the changing world we live in today during the

pandemic compared to before the pandemic. The overall effectiveness of comprehensive drug

diversion response programs during the pandemic has decreased because the usage of these

programs during the pandemic has declined (Nyhus, 2021; Porter, 2022). Because of the

pandemic, these studies supported the idea that early detection and prevention by nursing staff

was more prevalent than the effectiveness of the new software.

Effectiveness of Early Prevention and Detection by Nursing Staff

The study performed by Fan is a scoping review analyzing other studies including

quantitative and qualitative data to describe which safeguards worked most efficiently in a

diversion program (Fan, 2019). The study had begun by stating that drug diversion programs

were a necessity in every hospital facility. The research concluded that educating staff was

crucial in a drug diversion response program. Education for staff included ensuring that drug

handling policies and procedures were understood, describing characteristics of individuals

seeking to divert drugs, and also explaining the importance of reporting (Fan, 2019). A

randomized compliance check is recommended for staff education which assesses a staff
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member's adherence to a preferred practice (Fan, 2019). Overall, this source was confident in the

implementation of comprehensive drug diversion response programs and wanted to look at them

more indepth to improve them. This source is guiding the research into what exactly from the

drug diversion response programs are effective and should be implemented.

In the study performed by Karikari, which was a qualitative study, it describes the

nursing managers experiences with substance usage in nurses. It could be seen that most of the

nursing managers could not believe that someone working under them as a nurse could be

diverting and using substances (Karikari, 2022). It was found that only one of the nursing

managers out of the five that participated in the study were able to identify the initial stages of a

nurse using a substance even when all of them were confident that they would be able to

(Karikari, 2022). Once the nursing managers were able to identify the substance usage

appropriate action did take place. As stated in the research by Fan, nursing education is the most

important aspect of the drug diversion programs and it was apparent from the study performed

by Karikari as well.

The study by Simon talks on the importance of identifying drug usage behaviors. The

researcher focused more on what types of behaviors can be addressed (Simon, 2019). The study

did note that research performed to enhance the drug diversion response program does not

normally include the signs of substance usage. This study suggests more awareness about what

substance usage presents as in nurses compared to any other mental disorder. This source shares

a lot of similarities with the research performed by Karikari and the research performed by Fan.

This is because all three studies discussed the importance of being able to identify the signs of an

individual abusing a substance.

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The study by Solvang discusses the importance of attitude and knowledge about

substance usage among fellow nurses through an educational module and quiz. The most

significant increase in knowledge was shown when the researcher asked questions with the

theme of identifying diversion and related behaviors, consequences of diversion, how the

hospital treats nurses who divert drugs, and interventions (Solvang, 2022). This would mean that

the educational video and presentation did a successful job at educating them about substance

usage among nurses and can be reliably used in other drug diversion response programs. The

study also states that even with the evidence supporting the effectiveness of these educational

training programs there are not any standard training programs set in hospitals or nursing schools

(Solvang, 2022). As stated by the researchers of Karikari, Fan, and Simon, education is one of

the most important aspects of a drug diversion response program.

The study performed by Tellson was a study that provided training to nurses and staff

members that had access to controlled substances. The training included how to report,

document, and intervene if a nurse is suspected of substance usage. In 2020 drug diversion

officers investigated 164 reports that had been made while the drug diversion response program

was implemented (Tellson et al., 2022). Of the 164 reports, 22 cases were deemed to be

diversion and the other 142 were determined not to be diversion (Tellson et al., 2022). While it

seems that too many cases came back that had not been a diversion, the program also helps

determine what other factors could be causing these suspicions so the nurses can adjust and

implement new policies and practices that could be more effective. It also shows that the nurses

reporting and documenting these suspicions care about the safety and well-being of the patients

and of their fellow nurses.

Effectiveness of Technology and Data

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In the source titled Health Care’s hidden epidemic surveys were conducted that showed

that seventy-one percent of respondents had diversion prevention committees (Health Care's

hidden epidemic). This study showed that of the individuals surveyed, they thought that

diversion was difficult to detect but with their facilities approved diversion response program

they are confidently able to combat diversion. In this research, data is shown to be the most

needed aspect of diversion prevention and detection which is contradictory to what was said in

the research provided by Fan. Fan’s research suggested that education was one of the most

important aspects of the diversion program. However, in both studies prevention is a highly

implemented portion of the program.

In the study performed by Knight it showed the importance of using technology to detect

substance diversions. 19,037 of the medication movements were found to be from nurses, which

was over what any other department had encountered (Knight et al., 2022). This shows there is a

higher risk for drug diversion within the nursing profession. The technology used was 96.3%

accurate in detecting transaction patterns involving a high risk of diversion (Knight et al., 2022).

The purpose of prioritizing technology is due to the fact of human error that can be present when

having to detect someone with a substance usage issue. This was shown in the Karikari study

where of five nursing managers only one was able to detect someone using a substance. This

study suggests that the effectiveness of drug diversion response programs can be attributed to its

use of technology.

In the study performed by Perry & Vandenhouten it states that “the best detection

systems aggregate and analyze data” (Perry & Vandenhouten, 2019). Unlike Knight's study, the

software doesn’t detect patterns but instead a detection team is able to interpret the data

provided. The study would also support the idea of a detection team. This gets rid of the
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uncertainty of suspecting another nurse of abusing a substance by signs alone because the

detection team is able to look at the data themselves and interpret it by also knowing and seeing

the behavior of that suspected nurse.

The Effectiveness of the Drug Diversion Response Programs During the Pandemic

In the study by Nyhus, it was found that since the advent of Covid-19, healthcare

operations have deviated from the policies and procedures to address an overwhelming number

of people (Nyhus, 2021). This could mean bypassing preventative measures of diversion. This

study suggests more efficient and specific policies being put into place regarding controlled

substances (Nyhus, 2021). This is due to the lack of education and understanding of substance

usage. Because the healthcare team was taken off guard by Covid-19 they started prioritizing it

instead of drug diversion. This means the drug diversion response program was not being used

effectively due to a lack of urgency. More education needs to be provided to the staff about the

importance of the drug diversion response program.

The study done by Porter states that nearly 47% of individuals surveyed had agreed with

the idea that the pandemic has made it more challenging to track drug diversion (Porter, 2022).

As shown in the study by Nyhus the pandemic had a drastic effect on drug diversion response

programs. Because of increased stress related to Covid-19 it has become increasingly difficult to

suspect another nurse of substance usage. From 2019 to 2021 healthcare teams are doing less to

address drug diversion in hospitals, among which includes diversion awareness training (Porter,

2022). The response is the same as the Nyhus study, more education is needed on the importance

of drug diversion response programs.

Implementation
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Each of the sources looked at the comprehensive drug diversion response program in

depth because of its continued success in detecting substance usage among nurses. From the

sources it can be seen which aspects of the drug diversion program were the most beneficial.

This program can be implemented throughout any facility willing to include a new program into

the policies they already have set into place. The implementation process would first have to take

note of the decreased usages of the comprehensive drug diversion response program due to

Covid-19. The way this boundary can be faced is by continuous training on the importance of the

comprehensive drug diversion response program. The next intervention that seemed to be

attributing to the effectiveness of the program the most was the prevention and detection of drug

diversion by nursing staff. What seems to be effective in this aspect is training modules with a

presentation and compliance quiz. Implementing standardized uniform training in facilities

across the United States would make sure every nurse understands the importance of the program

and has the knowledge necessary to intervene if they suspect substance usage in a nursing

coworker. The training modules would have to include: detecting potential or suspected

substance usage among nurses, the importance of the program, documentation of the situation,

appropriate interventions, and encouraging creating an open and non-judgmental environment in

which nurses are supporting one another.

To further discuss the topic of substance abuse among nurses it would be even more

beneficial to implement other factors in conjunction with the comprehensive diversion response

program: offer education on coping mechanisms regarding stress and providing resources

including counseling services, build a judgment free environment which means breaking the

stigma surrounding substance abuse which could incline a nurse to reach out for help sooner, and

encouraging an environment in which nurses support one another. These elements would be
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preventative measures to ensure the nurse gets the help they need before turning to substance

usage, as stated beforehand workplace stress is a big factor in which nurses make the decision to

use substances.

The stakeholders would be the nurses who use substances and their coworkers. More

specifically it would be other nursing coworkers because nurses are more inclined to the baseline

of another nurse as they are around each other more often. Potential constraints would be the

willingness of nurses using substances to reach out. Providing education to break that stigma is

easy but coming forward about an issue is another matter involving the human psyche. People

who suffer from a mental illness or substance use disorder deny that they have a problem and are

most likely the last people to recognize that they have a problem. Another constraint could be the

readiness of a facility to adapt to a new policy or procedure.

The Evidence Based Practice model that is most applicable to the evidence based practice

project is the Stetler Model of Research. This model is used to “develop or refine policies,

algorithms, procedures, protocols, or other formal programs implemented in the institution”

(Grove & Gray, 2018, pg. 414). The research question asked involves a specific method of

detection within the nursing community to detect nurses that could be using substances while

working. The resources used for the research include those that could support/disprove the

effectiveness of the specific type of detection program. The PICOT question has the overall goal

of trying to find the most effective form of detection programs and education that will help

nurses identify and intervene when other nurses are using substances. As it relates to the Stetler

Model, the goal of this research is to re-evaluate detection methods so that coworkers and peers

can accurately identify substance usage and implement a plan of action when needed to support

their fellow nurses in getting the help they need.

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