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Literature4 Review of the Literature http://journals.lww.

com/nurseeducatoronline Nursing practice requires a high level of cognitive functioning for judgment and decision making. Safe practice involves adherence to regulatory and ethical standards, competent management of patients' biopsychosocial needs, accountability for nursing actions, and respect for human rights.3 Clinical performance in these domains may be adversely affected by a student's physical or emotional instability, which in turn may render him or her at least temporarily unfit to practice. Impaired practice has been generally defined as practice that is handicapped because of physical, mental, or other disease processes.4 Specific criteria have been set forth by individual state boards of nursing. Estimates of the prevalence of substance use among nurses and nursing students have been derived largely from studies conducted during the 1980s and early 1990s. The dearth of recent investigations likely reflects the trend away from nurses studying our own profession. While the earlier studies provide an important historical perspective, more recent work in the area confirms the need for continued concern. Indeed, the scope of the problem may well be underestimated, because substance use and addiction are often hidden or unreported and thus difficult to quantify.2 Chemical dependency has been identified as the most common cause of impaired practice. In 1990, more than 60% of nurses investigated by state boards of nursing were impaired as a result of drugs or alcohol.4More recent surveys suggest that 6% to 8% of nurses use alcohol or other drugs to an extent sufficient to impair their professional performance.5 Comparison with other groups has produced mixed results. Nurses have been found to use alcohol more but illicit drugs less than the general population,6 yet their use of illicit substances has been shown to be the same as, if not lower than, that of non-nurse controls.7 National data are unavailable regarding the prevalence of chemical dependency among nursing students. However, compared with liberal arts students, nursing students have demonstrated greater willingness to use depressants and narcotics.8 In a recent survey of 96 freshman nursing students, 20% reported consuming alcohol weekly or daily.9Earlier studies of nursing students revealed that 13% have problems with alcohol at school or work,10 and 14% acknowledge that alcohol interferes with performance at school or work.11 In addition, as many as half of recovering nurses describe themselves as having begun to abuse alcohol or drugs before or during nursing school.12,13 A random survey has shown that fewer than half of 107 randomly selected schools have policies in place to address the problem of chemical dependence.14 Several disorders may manifest themselves, either transiently or on a sustained basis, as impaired cognitive function. Depression, anxiety, diabetes, hypothyroidism, seizure disorders, asthma, arthritis, and even the common cold are but a few of the physiological and psychological conditions that afflict young and middle-aged adults and may affect their ability to perform. In some instances, it may be the treatment rather than the disorder that is the basis for impaired function. Iatrogenic effects of medications-such as the side effects of barbiturates, antihistamines, and corticosteroids-may alter affect, slow cognitive processes, and dampen reaction time. Rigorous schedules and insufficient time- and stress-management skills often plague the sleep patterns of students. The deleterious effect of sleep deprivation on job performance in the health professions has been shown in several investigations of medical residents. Sleep deprivation has been shown to increase errors in repetitive tasks or activities necessitating prolonged attentiveness and to increase irritability and emotional lability.15 Sleep deprivation has also been associated with a decrease in both verbal fluency and the ability to solve complex

16 Inadequate sleep has been related to diminished short-term recall and the ability to sustain visual attention. Policies have been developed within schools of nursing that have provided strategies for dealing with chemically dependent students specifically18 and unsafe practice generally. when a student's performance is impaired.17 Concern about a student's ability to perform safely may correspond to new or existing problems that may reflect a previously undiagnosed disorder.problems. the literature offers little guidance regarding the protocol for immediate removal from the clinical setting and subsequent actions aimed at helping the student constructively address the source of his or her impairmen . acute exacerbation of a previously diagnosed and controlled disorder. or a pattern of behavior that places patients at undue risk for injury.3 However.