Dr. Diane Kunyk
Nurses in every practice setting play a substantial role when supporting clients with addictions. What happens though, when a nurse - a frontline care provider responsible for patient safety - is dealing with their own addiction?
Diane Kunyk, an assistant professor with the Faculty of Nursing, became interested in addiction in nursing during her doctoral studies.
While brainstorming a research topic for a course, she was struck by the number of discipline decisions regarding nurses with addictions as she was reading a copy of the College and Association of Registered Nurses magazine, Alberta RN.
"I was instantly intrigued and wanted to understand it better, because it's disturbing on many levels," said Kunyk (BScN '78, MN '02, PhD '11). "It's disturbing knowing that nurses may be practicing while impaired, but it is also disturbing when someone suffering from a stigmatized disease is punished."
In a recent survey of Alberta nurses, Kunyk found that nurses have substance abuse and addiction rates consistent with the rest of Canada's population.
"It doesn't matter what occupational group you study, some individuals will have an addiction. Yes, there are nurses with addiction."
Over the course of their lifetime, about 6 million Canadians - or 21 per cent of the population - meet the criteria for substance use disorders, according to a Statistics Canada report from 2012. As of 2014, there are 406,817 regulated nurses eligible to practice in Canada. This means that over the course of their lifetime, approximately 87,000 of these nurses will meet the criteria for substance use disorder.
What bothers Kunyk is the disconnect she sees when the nursing profession focuses first on punishing addiction-related behaviours rather than helping fellow nurses struggling with a disease.
A nursing anomaly
"Most regulatory boards that oversee health professionals in Canada take a rehabilitative treatment approach when their members are reported for addiction-related behaviours," explained Kunyk. "This is not always the case with the nursing profession, where a disciplinary approach is sometimes taken."
Kunyk believes that addiction-related behaviours, like pilfering narcotics from the workplace, may be an indicator of an illness requiring help. The immediate rehabilitative objective is to have the health professional assessed and, if ill, moved into treatment. Following recovery, the health professional may return to work with ongoing support, which includes monitoring for relapses to ensure patient safety.
Unfortunately, this doesn't always happen within nursing. "If the case is sent to a hearing tribunal and the nurse is found guilty of professional misconduct, the nurse is disciplined and given conditions about going back to work. This process can take between 18 months and three years to complete. It is only after the resolution of the disciplinary hearing when rehabilitation is considered. "
Kunyk's research found that of the nurses she surveyed who self-identified with having an addiction, most were working and not in active treatment. When there is a fear of disciplinary action, individuals are hesitant to come forward and seek treatment.
"It's also the case that when peers or managers know of or suspect an addiction, they are reluctant to report their co-worker if the nurse may be punished; in this environment the issue is being kept silent."
Another challenge health professionals often face is that their peers are the ones who will be providing the addiction treatment. "The respondents in the survey were concerned that if they sought treatment, their colleagues would find out. This is a major barrier for individuals with a stigmatizing disease."
When addictions are being punished within the nursing profession, there is the possibility this also impacts the attitudes nurses have towards their patients with addictions. Punishment suggests that addiction is a choice; yet addiction is widely recognized within healthcare as a disease requiring treatment.
Where there's smoke, there's fire
Kunyk's interest in substance use disorders in nursing grew from her focus on another addiction - tobacco.
"While working on policies and programs related to tobacco reduction and cessation, I was struck by how similar the issues of substance use and tobacco use are," she said. Many people view smoking as a choice; nearly every news article that is published on the topic focuses on how smokers can change their habit.
"Smoking is not a habit," said Kunyk, "It is an addiction, just like other substance use disorders. Smoking is a disease and it is the leading cause of so many other diseases, such as cancer and heart disease."
With nearly 1 billion smokers worldwide, smoking remains the leading cause of death, disability and disease, killing around 6 million people each year.
"I know there are many, many health issues," said Kunyk, "But this one is critical. It is one that remains very challenging in our society because smoking is so normative; we all know someone who smokes."
Policy change - the smoking gun
In the early 2000s, Kunyk worked with Capital Health, now Alberta Health Services, to help develop and implement smoke-free policies for the Edmonton and area region.
It was very controversial at that time and incredibly challenging project for Kunyk. Many units objected to complying with the policy. For example, the unit with tuberculosis patients couldn't allow them outside as they would infect others and the palliative care unit wanted to allow patients to enjoy their last pleasure.
"There wasn't a choice," said Kunyk, "There is no risk-free level of second-hand smoke exposure. We had to change our policy for occupational health reasons and for the safety and health of the patients."
As with any policy, the implementation of the smoke-free policy had unattended consequences. One that left Kunyk particularly disheartened was that individuals who do smoke now must leave the building. Nicotine withdrawal can be readily managed within the hospital on a similar model to alcohol withdrawal. Yet vulnerable patients that smoke often suffer withdrawal needlessly or endure the indignity of going outside in their pyjamas to smoke.
"I felt we were further stigmatizing people who do smoke and that's the last thing I'd ever want. This is actually what spurred me to complete my doctoral studies; I wanted a better understanding of policy - how it is developed, how to make it as ethical as possible, and the role that health professionals can play in its implementation."
Kunyk believes that each and every health professional team has a role to play in helping people, either to not start smoking, to cut back, or to quit. "Nurses are really well suited for this role, because we see the same people often and we can help in many ways as we continue in our interactions with them. Psychosocial interventions are what nurses' shine at and these are also some of the most effective ways to help with tobacco cessation."
In an ideal world, Kunyk would like to see addiction recognized and treated as an illness to the same extent as other chronic conditions such as heart disease.
"If addiction received the same amount of emphasis during the education of health professionals as heart disease, if our provision of care was directed to the same extent, then stigma would be reduced, and lives would be saved," she said.
Kunyk believes that as the largest body of health professionals, nurses can and should make a difference. Where better to start implementing addiction support or making changes to the way nurses approach addiction treatment than within the profession itself.