Extending a hand of care: Supporting managers to support nurses and midwives dealing with substance issues

In this piece I’ll use the term ‘problems with substances’ to encompass both problematic substance use and substance use disorder. I am defining problematic substance use as when the use of alcohol, drugs or other substances contributes to and negatively impacts on the nurse or midwife’s workplace practice. A substance use disorder is defined here (from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (2013) as the abuse of, misuse of or dependency on alcohol or drugs.

In Australia, employers have a legal obligation to address alcohol and other drug issues in the workplace through the ‘duty of care’ provisions in the OHS Act 2011. So how can Nurse and Midwife managers compassionately and sensitively provide that duty of care to nurses and midwives experiencing problematic substance use and substance use disorders? 

Compassionate approaches create better outcomes for all and nurses and midwives can be supported to sustain recovery and remain in the workforce — while also ensuring public safety.

The management of nurses and midwives with problems with substances must include approaches that are empathic, supportive and compassionate. Recently we have moved away from punitive and regulatory management responses and increasingly implemented responses that seek to provide early identification, proactive and confidential treatment, and where there is an identified and diagnosed substance use disorder — supportive of monitoring of on-going recovery. 

While nurses and midwives tend to have the same rates of problems with substances as the general public, the nature and stressors of their work make them vulnerable to regular and problematic substance use and dependence. Current estimates are that the percentage of nurses (and potentially midwives), with problems with substances and dependency ranges from 2–10% and some estimates suggest it may exceed 14–20%. Additionally, the pressures of the COVID-19 pandemic have increased workplace stress and this is likely to have intensified nurses and midwives’ vulnerability to regular and problems with substances — perhaps as a stress-management response. 

Your behaviour as a manager, and the culture you create in your nursing or midwifery team is the biggest influence on work practice and workplace experience. We know that as managers you are most often the person a nurse or midwife will disclose an issue to, and the first person that might notice they are struggling at work. 

Yet, we also know that the issue of substance use is not adequately managed in the workplace through appropriate support and training. Only 30% of organisations provide guidelines for managers on how to deal with disclosure and how to refer for support, with just 27% giving information for employees about disclosing a problem with alcohol and/or drugs. So, it’s critical that Nurse and Midwife managers are knowledgeable about problematic substance use and substance disorders in the workplace and know (and/or seek guidance) on how to appropriately manage and support their nurses and midwives when the issue arises.  

It is also equally important to be aware of your own value judgements and beliefs about substance use and substance use disorders, so that they are not inadvertently negatively impacting the care and compassion your nurse or midwife requires from you in the management and support of this complex issue.  

Nurses and midwives who have problems with substances should viewed with compassion and should not be labelled in a negative or derogatory light. There are always factors occurring in their lives outside the workplace that aren’t always known or visible and are likely to be contributing to this issue.  Substance use is often a response to trauma or distress and may be used as a solution to a deeper problem or set of problems. So, as you endeavour to provide support to your nurse or midwife struggling with their problems with substances, it can be helpful to remember this. In addition, it’s important to acknowledge that you won’t have all the answers. You don’t have to be the expert. 

It might also be important to keep in mind that in your efforts to support, understand and manage the problem with your nurse or midwife — you too could benefit from guidance and support yourself. Don’t hesitate to contact your Human Resources department or the confidential support and information provided by Nurse & Midwife Support on 1800 667 877 or by email.  

Learn more about what 'substantial harm' means from Ahpra. 

Not every nurse or midwife who uses drugs and/or alcohol will misuse or become dependent on them. However, even infrequent problematic or excessive use may impact adversely on work practice and the overall workplace environment. That’s why it is important for nurse and midwife managers to recognise problems early. As a manager you know your staff well and recognising issues early supports better outcomes.   

It is essential that if you believe that a nurse or midwife has a problem with alcohol or drugs, not to assume that there is one specific problem behind what is going on for them, or one single approach or even solution to this issue. 

Every nurse or midwife and every workplace situation needs to be dealt with uniquely, with sensitivity and understanding. Any interventions with nurses or midwives about their alcohol or drug use should value them, the profession they (and you) love, and the patients/clients with whom they work.

There is no one single way of managing this issue, but your response should be grounded in empathy. The key is that it is no different to the way in which you would attend to the problems of patients — with concern, compassion, sensitivity and care. 

While it is not my intention to provide an exhaustive list of behaviours that may indicate a nurse or midwife has problems with substances, there are some indicators that must be addressed and not ignored when they come to attention. A reminder here also of the importance of providing understanding and sensitivity to those who come to you to talk about or report their colleague’s workplace practice of behaviour. Speaking up about a concern or problem with their colleague can be an extremely difficult thing to do. They too require support and discretion. 

However, central to any workplace behaviours which may indicate a problem — and therefore your intervention — is paying attention to the frequency of those behaviours, if other team members report them to you, and if the safety of others is compromised or at risk.  

Some of the more commonly documented workplace behaviours that may indicate problematic substance use or substance disorders are: 

• problems in performance and punctuality
• frequent tiredness and falling asleep on the job
• volunteering to administer narcotics to other colleague’s patients
• smelling of alcohol
• repeated failure to remember work tasks
• unexplained absences 
• incomplete or erroneous medication charting
• repeated errors or discrepancies.  

Many of these issues are not exclusive to problems related to substances and could also indicate other mental or general health issues, so it is important to keep an open mind. Again, the emphasis within your approach is the need for sensitive and caring intervention.

Also, if a nurse or midwife does attend work clearly under the influence of drugs or alcohol, you should act with immediacy to deal with any safety-critical issues. Your organisation will have a policy and procedure to support how situations like this should be managed and if the situation involved other staff, consider if debriefing for yourself and others is required. 
 

Though the emphasis so far has been on early identification, I would like to back-track to the issue of prevention.  Your primary role in prevention is to establish a positive and supportive workplace environment and work practices.

In the Line Manager’s Guide – Drug and Alcohol Misuse, the CIPD highlight the value of a supportive workplace environment. I have adapted some of their tips to the nursing and midwifery field. 

• create a caring and supportive environment where nurses and midwives feel able to ask for help and respond with immediacy and sensitivity when this occurs
• provide education and staff development on harmful use of alcohol and other drug issues and substance use disorders  
• be sensitive to heavy workloads and reducing work related stressors where possible
• where possible allow rotation of work areas and offer changes to contracts and rosters for nurses and midwives in crisis’ 
• avoid fuelling a drinking culture — consider the implications for wellbeing and inclusion when planning work events
• ensure staff are aware of drug policies and procedures and that incident reports where there are drug count anomalies are completed promptly
• have clear and thorough audit processes for drug purchasing, distribution, handling, administration and storage of medications and that these practices comply with professional and legal requirements and
• ensure your nurses and midwives get regular clinical supervision that is constructive and supportive.

Whether you have identified problematic substance use or a diagnosed substance use disorder, it is important to ask the nurse or midwife you are supporting what they think they need. Because every nurse or midwife’s situation is unique, it will be crucial to hear and understand their perspective and situation. This can be placed alongside the supports and treatments that are available. Prepare for them to be embarrassed, emotional or even angry. Some nurses or midwives may require time out away from the workplace, work-role adjustments or temporary reduction in workloads. Others may find the structure of regular work helpful but need flexibility in rostering to attend treatment appointments. As a manager you have a crucial role in facilitating and supporting a range of options that may allow the nurse or midwife to either remain in the workplace or re-integrate back into it. 

In summary, when our colleagues are struggling with problematic substance use or have a diagnosed substance use disorder – they need us to extend to them, our hand of care. 

I finish with a point from Heather Pickard, registered nurse and chair of the NMHPV board. Heather shared her story on the NMHP podcast, Conversations that Connect Episode 1 - Keys to a nurse or midwife thriving in recovery from their alcohol or other drug (AOD). Heather shared her personal story, which is a reminder to us all:  

“Sometimes when we're at a very low period in our lives, particularly around something like substance abuse (which is so loaded with shame and stigma), we can actually not see hope for ourselves. Not only can't we see hope for ourselves in establishing recovery but the idea of being able to return in a meaningful way to the profession that we love can seem so distant”.  

Heather is a wonderful clinician who has been able to thrive in her beloved profession. With support, your nurses and midwives have the best potential to find hope for the future and recover. 
 

Helping your team to navigate these issues can be stressful. If you’d like to chat about it, reach out to Nurse & Midwife Support — free, confidential, 24/7. Give us a call on 1800 667 877 or by email. 

Tessa Moriarty is a credentialed Mental Health Nurse Consultant with over 30 years’ experience across public, private and primary health care, mental health and drug and alcohol settings. She has worked in a variety of senior leadership and executive roles and is an experienced group facilitator, clinical supervisor and psychotherapist. Much of Tessa’s work in recent years has focused on supporting those working in clinical settings – providing individual and group clinical supervision and reflective practice. She also works as a mental health nurse consultant for Primary Health Networks and always tries to bring a humanistic approach to the clinical governance and service review projects she undertakes.