WEBVTT
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- [Woman] Dr. Foli is an award-winning researcher,
educator, and author, who examines predictors
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of substance use in nurses,
specifically the role of psychological trauma.
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She has formulated the middle-range theory of nurses'
psychological trauma, in which she introduces
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a discourse of nurse-specific traumas.
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Her book, The Influence of Psychological Trauma in
Nursing, won two first-place awards in the
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Wolters Kluwer American Journal of Nursing
Book of the Year Awards 2019
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for psychiatric mental health nursing
and nursing education.
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- [Dr. Foli] Hi.
My name is Karen Foli.
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I'm from Purdue University, West Lafayette, Indiana.
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I'm here to talk to you today
about substance use disorders in nurses,
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exploring psychological trauma as a risk factor.
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What I'd like to cover today are several objectives.
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First, I'd like to delineate some emerging patterns in
the literature that I've noticed as I do literature
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reviews for grant applications
and peer-reviewed papers.
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Next, I'd like to specifically describe the project
about substance use in nurses that was just completed.
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This project was funded by the National Council of
State Boards of Nursing:
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Center for Regulatory Excellence.
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Third, I'd like to describe some of the conclusions
and regulatory implications of the project
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and the research findings.
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And last, I'm going to argue for the need for future
investigations in registered nurses who struggle
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with substance use,
particularly from an organizational level.
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So to start with the two emerging threads in the
substance use literature surrounding nurses,
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what I have found are these two kind of divergent
threads, although there is some overlap in them.
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The first thread is what we call foundational
literature, and that literature spans a little bit
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farther back in time,
but it relates to prevalence rates, risk factors,
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how we measure that,
regulatory considerations, and so forth.
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The second emerging thread that I've noticed takes more
of a critical theory view of substance use in nurses.
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We talk more about the context of substance use in
nursing as a particular and unique profession
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in a high-stakes, high-pressured environment.
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I call your attention to the work of Ross and
colleagues, especially in her article,
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"A Two Glass of Wine Shift."
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It really gives us a broader understanding of this
phenomenon within the lived experiences
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of registered nurses.
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I could spend an entire day discussing the background
of substance use in registered nurses,
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but for today I'm just going to briefly talk about
prevalence and some risk factors that we know of.
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Right now our understanding of prevalence of substance
use is about that of the general population,
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about 6% to 8%.
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Some would argue, however, that it's
much higher than that.
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And there is a social desirability component
to studying this phenomenon.
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We also know there's some risk factors, such as access
to medications and drugs, stress levels,
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self-medicating, sometimes for musculoskeletal injuries
that nurses have experienced,
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a lack of education regarding substance misuse and use,
attitudes of nurses, and their demanding shift
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schedules and rotations.
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We also know that there are specialty areas, such as
nurse anesthetists, who have a known higher rate
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of substance use and misuse.
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But for today, I'm going to spend the rest of this
presentation on the project that I referenced
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on the first slide.
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It was a two-phase study that really was
about three years in length.
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We're just finishing up.
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Really proud of this study with my colleagues,
Lingsong Zhang and Blake Reddick.
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I think we've produced some nice literature
and disseminated it in various conferences.
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Our Phase 1 had to do with document analysis and
the legal court proceedings that took place between the
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Indiana State Board of Nurses and nurses in front of
the board for substance use issues.
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The second phase comprised of qualitative
and quantitative projects, was larger in scope,
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and I will describe it in detail later.
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We have for our quantitative analysis almost 1,500
nurses responding to our solicitation.
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So back to Phase 1.
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This, again, was a qualitative analysis of court
proceeding documents that are publicly available
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in the state of Indiana.
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I know states vary in terms of the public availability
of these court proceedings.
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What we asked as our overarching research question was
what are the safety, regulatory,
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and professional issues that
influence nurses' substance use
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who present before the board for disciplinary action?
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We wanted specifically to look at
the temporal patterns that occurred.
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We know substance use is a chronic disease,
we know that there is recurrence,
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and so we really wanted to take an examination of these
court documents, which, at first glance, appeared
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somewhat sterile and generic.
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But as you got further and you traced back the
trajectory of some of the nurses who were experiencing
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this chronic disease, became much more enlightening.
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Here's an example of one of the license litigation
court documents that we reviewed.
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We've obviously marked out any identifying information,
but you can see, it is a court document.
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And what we did was we selected from our sample.
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We started in 2017, taking some samples
of various documents,
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and realized that these narratives,
I call them narratives, again, court documents,
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these texts, stretched farther back in time.
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So we went back to 2014,
got some more RNs for our sample.
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So ultimately, our total sample was
51 RNs and 236 documents.
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And by documents, we really...we're
talking about court events, court proceedings.
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If you look in the footnote,
each of those documents was between 7 and 10
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pages in length.
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We filled about three 3-inch binders with all of these
data in them, and it was something that we couldn't do
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using a qualitative software.
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We really needed to do it ourselves.
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So I had another coder, Dr. Reddick,
who is also helping me with this analysis.
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We came up with these themes,
and I will go through...all of the presentation
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descriptions I'm going through are published
peer-reviewed papers,
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and I have those citations
at the end of this presentation so that
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you can look more in depth at all of these
findings that I'm describing for you.
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I'm going to highlight some of the themes for you.
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There's a critical junction of the various actors in
the process, and by actors,
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I mean those social people who are there for this
particular moment in time.
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They could be the nurse's attorney, they could be
the members of the state board of nursing,
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it could be the attorney general of the
state of Indiana, it could be the Indiana State
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Nurses Assistance Program
program representative, and so forth.
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They all had divergent goals, though, if you will,
and that's important to note as well.
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There are also emerging groups who appear before the
board, those individuals with really a chronic disease
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or relapse and recurrence was very much in the picture.
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There was individualized context in terms of the court
decisions as well as standardized discipline in terms
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of probation, suspension of licensure.
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And we know that this type of disease is one that the
overall goal is to continue using.
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And so we saw that this was deliberate diversion,
deceit, and deception, and ultimately, a significant
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threat to public safety and quality care.
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This is an example of what we wrote up after looking.
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This was probably maybe 100 pages of documentation that
we traced back for this particular individual.
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You can see her nursing license was issued in 1978,
but you still see her having interactions with the
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board in 2017.
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We saw not uncommon for nurses to abruptly leave their
organizations if they were confronted with substance
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use and ultimately able to secure additional employment
sometimes and not unfrequently in long-term care
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facilities, who are typically very understaffed
and looking for registered nurse help.
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Our Phase 1 study conclusions, then, is that
this is a complex process.
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It's not simple, it's not straightforward.
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In the study that is published,
we have a workflow chart that shows just how the nurse
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would navigate or go through this process from the time
of recognition of substance use issues
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and then coming in front of the board, etc.
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There is this juncture, if you will,
of various parties who are involved in this process,
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and then, again, they each compete for different goals,
from the nurse, who is trying to maintain a livelihood,
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to the board, who is trying to maintain public safety.
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We also verified that opioids and alcohol are the
leading substances used by nurses.
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So now we're going to shift to Phase 2,
which was a mixed-method survey design.
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Our data were collected from an online survey.
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And just to back up a little bit, let me give you some
background about this particular sample.
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We purchased with the grant funding the entire database
of registered nurses from the state of Indiana.
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It was comprised of 160,000 registered nurses'
addresses, their license status, etc.
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From that, we took a randomized stratified sample of
registered nurses based on year of licensure.
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We used the postal mail because we did not have access
to email, and mailed off 4,000 letters, giving them,
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registered nurses, an idea of the study, the purpose,
and how they could access our web page which we created
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for the study.
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From this web page, then,
they had access to resources if they were struggling
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with substance use as well as the online,
we used Qualtrics as our survey platform,
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link to the online survey.
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This survey contained many validated tools,
which I'll talk about in just a moment.
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I'm going to kind of go back in time.
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One of our open-ended questions of the survey was,
"Please add any additional comments related to
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substance or alcohol use that you've experienced
or witnessed in registered nurses."
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Of the ultimate 1,478 nurses who responded
to our postal mailings,
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373 went ahead and gave us
open-ended responses to this question.
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From the content analysis..so we used
a little bit of a different way
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of approaching these data, and we were surprised at the
richness of the data that we received.
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Online interviewing, if you will, is a solid way,
I think, of understanding this phenomenon,
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and this, I think, supported that conjecture.
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This article was published in the
American Journal of the...or the
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Journal of the American Psychiatric Society.
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I heard about a nurse who...
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And what we found was that there was different
social proximity to nurses who are using substance use.
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I think one of the novel findings was that nurses who
are using and misusing substances,
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it's not just confined to that individual,
but there are real influences by that use on the unit,
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at the bedside, and in the organization.
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We saw this individual process go from vulnerability to
outcomes, oftentimes negative outcomes,
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and, again, that this use reflected bedside, system,
and organizational spaces and effects.
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Then there were those that said that they had never had
any exposure to substance use in nursing.
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Our conclusions, then, from the content analysis of
those 373 nurses who gave us information was that
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about 25% of the nurses actually disclosed that they
were either recovering or actively using substances.
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But there was...75% of those who gave us feedback were
not actively using but still wanted to report how they
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were affected by this phenomenon.
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They described peers who were using,
they described suicides,
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they described finding nurses in bathrooms,
they described a lot of things that obviously had
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affected them.
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And it kind of teeters on the border of
secondary traumatic stress for them.
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I did not see in the data any reports of really
escalating things or talking to nurse managers
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to any great extent.
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And then, thirdly, there were individual factors and
system-related failures that appear to be contributors
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to substance use in nurses.
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So for the rest of our time,
I'm going to talk about the third study that we did
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in this project, Study 2 of Phase 2.
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And this was the quantitative approach
to these data that we took.
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We really took a focused approach to trauma,
psychological trauma, to see if there were
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relationships or if we could somehow use trauma
as a predictor to substance use in nurses.
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We also looked at risk rates in terms of these data.
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So what are the screening rates of tobacco, alcohol,
and other substance use?
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And again, what are the predictor
variables of such substance use?
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So, again, in this Phase 2, Study 2,
we had almost 1,500 nurses who contributed to our data.
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And we incentivized them with a $50 Amazon gift code,
which, again, was made possible through the funding
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that we received.
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We were very pleased, also, that these individuals
completed, we had a very high completion rate.
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So our data set was very, very complete.
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We had very few missing data pieces.
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As you can imagine, we had characteristics of our
sample, which included 92% being female,
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a mean age of 44 years, most of them were Caucasian,
married, and not of Hispanic ethnicity.
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Average time of nurse licensure was 18 years.
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This is a very condensed slide of all of the validated
measures that we used.
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So in addition to the demographic variables that we
asked, we had a brief survey
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for organizational support, depression, anxiety,
resiliency, optimism, religiosity,
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and then we also looked at those trauma- related
variables, which, again, was the focus of the study.
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There's been a lot of press, a lot of attention given
to adverse childhood experiences,
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and we know from some of the emerging literature in
student nurses that that is a factor for them
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in terms of substance and alcohol use.
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We used a Life Events Checklist to determine
what had happened in terms of life,
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what I call part of that humankind trauma.
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We also looked at workplace violence, lateral violence,
or negative behaviors in the workplace,
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and second-victim items which relate to the occurrence
of a medical error, and then if a medical error
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has happened, if they are experiencing psychological
harm from those errors.
00:17:13.640 --> 00:17:18.230 position:50% align:middle
So our outcome measure was the World Health
Organization ASSIST tool.
00:17:18.230 --> 00:17:23.320 position:50% align:middle
This is a screening tool that's used both in primary
care and research studies.
00:17:23.320 --> 00:17:29.910 position:50% align:middle
It follows the SBIRT pattern, screening,
brief intervention, and treatment.
00:17:30.788 --> 00:17:36.865 position:50% align:middle
So we looked at substances individually, tobacco,
alcohol, and other substances.
00:17:37.018 --> 00:17:40.177 position:50% align:middle
And again, this is related to risk use.
00:17:42.258 --> 00:17:53.508 position:50% align:middle
So this chart here talks about the minimal risk is the
no intervention, the middle column is receives
00:17:53.508 --> 00:18:01.510 position:50% align:middle
brief intervention, what we call moderate risk,
and the far-right column is more intensive treatment
00:18:01.510 --> 00:18:02.908 position:50% align:middle
or high risk.
00:18:03.520 --> 00:18:12.660 position:50% align:middle
As you can see, the range of scores in the middle that
has got the red circle or oval around it really is
00:18:12.660 --> 00:18:13.720 position:50% align:middle
a large range.
00:18:13.720 --> 00:18:19.060 position:50% align:middle
So what we did was we looked
at low moderate and high moderate risk.
00:18:19.060 --> 00:18:25.053 position:50% align:middle
We divided that category into two separate
moderate risk categories.
00:18:25.497 --> 00:18:28.540 position:50% align:middle
And that's what you see on this slide in red.
00:18:28.610 --> 00:18:37.221 position:50% align:middle
So interestingly enough, just coincidentally,
the moderate risk, both low and high,
00:18:37.221 --> 00:18:44.055 position:50% align:middle
for both tobacco and alcohol was
11.6% for each of those.
00:18:45.123 --> 00:18:50.269 position:50% align:middle
Other substance, moderate risk was
10.4% for the nurses.
00:18:53.513 --> 00:19:00.225 position:50% align:middle
We also performed regression analysis to look at what
might be predictors based on those measures that I
00:19:00.225 --> 00:19:05.768 position:50% align:middle
reviewed with you, what's going to be
coming out in our final regression model.
00:19:06.357 --> 00:19:12.123 position:50% align:middle
Our regression coefficients were fairly modest,
but when you talk about this type of complexity
00:19:12.123 --> 00:19:17.757 position:50% align:middle
in a human science study,
I think that they are leading us towards novel
00:19:17.757 --> 00:19:20.160 position:50% align:middle
information that we can build upon.
00:19:20.787 --> 00:19:26.362 position:50% align:middle
For tobacco use, we found that those ACE scores
popped up as highly significant.
00:19:26.937 --> 00:19:33.496 position:50% align:middle
We also found that the Lateral Violence Question 38,
which has to do with them losing their patience and
00:19:33.496 --> 00:19:40.815 position:50% align:middle
directing behaviors that can be interpreted as violence
towards co-workers, popped up as well.
00:19:41.256 --> 00:19:49.197 position:50% align:middle
We also see the depression and anxiety,
and past ISNAP score or ISNAP involvement.
00:19:49.197 --> 00:19:54.226 position:50% align:middle
Again, ISNAP stands for Indiana
State Nursing Assistance Program.
00:19:54.226 --> 00:20:01.105 position:50% align:middle
It's a monitoring program conducted by the state of
Indiana to help monitor nurses who are either
00:20:01.105 --> 00:20:05.472 position:50% align:middle
self-identified or have been
identified as using substances.
00:20:07.605 --> 00:20:12.940 position:50% align:middle
Our alcohol regression model, little bit higher,
but you, again, see some trauma
00:20:12.940 --> 00:20:14.918 position:50% align:middle
variables percolating through.
00:20:15.235 --> 00:20:20.045 position:50% align:middle
The Life Events Checklist, which has to do with things
that have happened to them or they've witnessed,
00:20:20.045 --> 00:20:25.545 position:50% align:middle
or things that have happened on the job,
and the Lateral Violence Question 39, which had to do
00:20:25.545 --> 00:20:31.406 position:50% align:middle
with how often have you crossed the line and used
behaviors that could be interpreted as lateral
00:20:31.406 --> 00:20:33.381 position:50% align:middle
violence towards others.
00:20:33.626 --> 00:20:36.632 position:50% align:middle
Again, you see depression and anxiety as well.
00:20:38.646 --> 00:20:42.764 position:50% align:middle
Finally, our third regression model had
to do with other substances.
00:20:42.896 --> 00:20:51.994 position:50% align:middle
The ASSIST tool really goes into specific substance
use, like, benzodiazepines, opioids,
00:20:51.994 --> 00:20:53.206 position:50% align:middle
those types of things.
00:20:53.206 --> 00:21:00.841 position:50% align:middle
However, we felt that the Ns were small,
so we did collapse those into other substances.
00:21:01.230 --> 00:21:08.490 position:50% align:middle
These findings can be found in an in-press article in
the Western Journal of Nursing Research.
00:21:08.490 --> 00:21:13.070 position:50% align:middle
But, again, in terms of the model,
you see three trauma-related variables in this
00:21:13.070 --> 00:21:22.111 position:50% align:middle
final model, the adverse childhood experience score,
the life events, and Lateral question 37,
00:21:22.111 --> 00:21:28.900 position:50% align:middle
which has to do with how often do you see co-workers
losing their patience and directing behaviors that can
00:21:28.900 --> 00:21:30.902 position:50% align:middle
be interpreted as lateral violence.
00:21:30.902 --> 00:21:34.015 position:50% align:middle
So witnessing this towards others.
00:21:36.722 --> 00:21:42.532 position:50% align:middle
So to sum up what we found
and in terms of making sense of these three models,
00:21:42.532 --> 00:21:48.353 position:50% align:middle
we saw that depression and anxiety,
and questions related to the lateral violence were
00:21:48.353 --> 00:21:50.547 position:50% align:middle
in each of the three models.
00:21:51.152 --> 00:21:58.739 position:50% align:middle
We also saw indications of trauma in terms of adverse
childhood experiences or life events in all three
00:21:58.739 --> 00:22:00.235 position:50% align:middle
models as well.
00:22:02.874 --> 00:22:06.602 position:50% align:middle
Of course, there are limitations to every study,
and this study is no different.
00:22:06.946 --> 00:22:13.106 position:50% align:middle
I alluded to social desirability earlier on, and that
is certainly the case when you try to measure substance
00:22:13.106 --> 00:22:21.716 position:50% align:middle
use in a profession such as nursing where livelihoods
are at stake and in addition to all of the difficulties
00:22:21.716 --> 00:22:26.026 position:50% align:middle
in terms of this phenomenon in general.
00:22:26.026 --> 00:22:31.202 position:50% align:middle
I had a nurse...several nurses call me, actually,
wanting reassurances that these data were
00:22:31.202 --> 00:22:33.757 position:50% align:middle
confidential and anonymous.
00:22:33.952 --> 00:22:40.165 position:50% align:middle
They were very hesitant to really report use in the
questionnaires and sample.
00:22:40.302 --> 00:22:42.847 position:50% align:middle
And so that is certainly a limitation as well.
00:22:43.052 --> 00:22:50.521 position:50% align:middle
It was a very homogeneous sample, and other substance
use category Ns or frequencies were very small.
00:22:51.602 --> 00:22:55.432 position:50% align:middle
These are also...this wasn't in any way
an experimental design.
00:22:55.432 --> 00:23:04.113 position:50% align:middle
It was basically an association trying to look at
variables that could predict various substance usages.
00:23:06.375 --> 00:23:10.059 position:50% align:middle
So I got some conclusions that I'd
like to share with you now.
00:23:10.445 --> 00:23:18.192 position:50% align:middle
Nurses, then, are at moderate risk for tobacco use,
alcohol use, at 11.6%.
00:23:18.309 --> 00:23:24.375 position:50% align:middle
If you think of 100 nurses, 11,
almost 12 of them, are at moderate risk for these
00:23:24.375 --> 00:23:28.707 position:50% align:middle
substances, and for other substances, about 10%.
00:23:28.708 --> 00:23:32.732 position:50% align:middle
These are concerning estimates in terms of risk.
00:23:33.759 --> 00:23:40.882 position:50% align:middle
Trends in substance use in nurses, I believe, warrants
further study, both on an individual and system level.
00:23:40.882 --> 00:23:48.451 position:50% align:middle
And we have this information for those qualitative data
that I talked about before, that it's not just the
00:23:48.451 --> 00:23:54.798 position:50% align:middle
nurse who is using the substances,
but there are ripple effects in the organization,
00:23:54.798 --> 00:23:59.121 position:50% align:middle
on the unit, and certainly for regulatory
and patient safety issues.
00:24:01.740 --> 00:24:07.724 position:50% align:middle
I have another study that I have that's ongoing that
was funded by the college that I reside in,
00:24:07.724 --> 00:24:11.340 position:50% align:middle
and it has to do with COVID
and nurses on the frontline.
00:24:11.340 --> 00:24:17.670 position:50% align:middle
And I have detected through the qualitative work that I
am doing a substantial increase in substance,
00:24:17.670 --> 00:24:24.840 position:50% align:middle
particularly alcohol use, in nurses, which has been
verified by the ANA Enterprise mental health survey
00:24:24.840 --> 00:24:31.347 position:50% align:middle
that was recently done that found during the pandemic,
18% of the nurses have reported
00:24:31.347 --> 00:24:33.387 position:50% align:middle
increased alcohol intake.
00:24:33.803 --> 00:24:37.107 position:50% align:middle
And I should have emphasized this more at the
beginning, but I would say that this
00:24:37.107 --> 00:24:39.503 position:50% align:middle
project was pre-pandemic.
00:24:39.637 --> 00:24:43.967 position:50% align:middle
So all of those figures I have just shared with you
and all those themes that I just shared with you
00:24:43.967 --> 00:24:46.638 position:50% align:middle
were pre-pandemic COVID-19.
00:24:47.707 --> 00:24:55.246 position:50% align:middle
So I think what the pandemic has done is push the
high-pressure, high-stakes environment to a new level
00:24:55.246 --> 00:25:01.600 position:50% align:middle
and that there is even more trauma that's going on,
and you're seeing PTSD really talked about more openly
00:25:01.600 --> 00:25:03.729 position:50% align:middle
in terms of the pandemic itself.
00:25:04.220 --> 00:25:10.430 position:50% align:middle
I believe that there's a gap in understanding the
nurses' experiences in terms of substance use in the
00:25:10.430 --> 00:25:15.479 position:50% align:middle
organizational interface, and I would really like that
as my next step of investigation.
00:25:17.110 --> 00:25:22.470 position:50% align:middle
Here are the articles that I've mentioned to you that
you can look up that have been disseminated interview
00:25:22.470 --> 00:25:24.090 position:50% align:middle
in peer review publications.
00:25:24.090 --> 00:25:30.694 position:50% align:middle
The one that's not highlighted had to do with another
open-ended question in the survey in Phase 2 and it
00:25:30.694 --> 00:25:32.634 position:50% align:middle
specifically asked about trauma.
00:25:32.634 --> 00:25:37.694 position:50% align:middle
And I'm so grateful to the National Council State
Boards of Nursing because I was able to glean from this
00:25:37.694 --> 00:25:42.834 position:50% align:middle
data a new type of psychological trauma that's specific
to nurses and that is insufficient resource trauma,
00:25:42.834 --> 00:25:48.354 position:50% align:middle
that trauma that occurs with lack of staffing,
lack of personnel, lack of access to other
00:25:48.354 --> 00:25:56.224 position:50% align:middle
professionals and supplies such as PPE that nurses have
faced particularly since the pandemic have started.
00:25:57.443 --> 00:25:59.434 position:50% align:middle
So I want to thank you for your time.
00:25:59.434 --> 00:26:02.635 position:50% align:middle
I hope this has been helpful and enlightening to you.
00:26:02.880 --> 00:26:09.110 position:50% align:middle
And my sincere gratitude for this funding and what it
has brought to light in terms of substance use
00:26:09.110 --> 00:26:10.710 position:50% align:middle
in registered nurses.
00:26:10.710 --> 00:26:11.593 position:50% align:middle
Thank you.
00:26:32.821 --> 00:26:35.311 position:50% align:middle
Hello.
I hope you've enjoyed the presentation.
00:26:35.311 --> 00:26:38.411 position:50% align:middle
I hope it was helpful in understanding this phenomenon.
00:26:38.411 --> 00:26:42.231 position:50% align:middle
I want again extend my appreciation to the National
Council State Boards of Nursing
00:26:42.231 --> 00:26:45.011 position:50% align:middle
for funding this project.
00:26:45.011 --> 00:26:48.251 position:50% align:middle
I have some questions.
00:26:48.251 --> 00:26:52.521 position:50% align:middle
One has to do with how cannabis and marijuana use was
situated in the study.
00:26:52.521 --> 00:26:58.401 position:50% align:middle
This is a really, really good question,
a complex question, and I also received this kind
00:26:58.401 --> 00:27:05.964 position:50% align:middle
of query when we were submitting our final paper from
one of the reviewers that was peer reviewing it.
00:27:05.964 --> 00:27:12.184 position:50% align:middle
Because the study was located in Indiana,
marijuana use is still illegal.
00:27:12.184 --> 00:27:18.544 position:50% align:middle
So it really fell into the other substance use
categories and the ASSIST tool specifically
00:27:18.544 --> 00:27:20.244 position:50% align:middle
teases it out.
00:27:20.244 --> 00:27:24.624 position:50% align:middle
So for this study, cannabis
was located under other substances.
00:27:24.624 --> 00:27:28.314 position:50% align:middle
Again, I would refer you to the Western Journal of
Nursing Research, there's an EPUB that
00:27:28.314 --> 00:27:30.532 position:50% align:middle
was just released.
00:27:30.532 --> 00:27:31.822 position:50% align:middle
So I hope that's helpful.
00:27:31.822 --> 00:27:34.242 position:50% align:middle
Let's see.
00:27:34.242 --> 00:27:40.662 position:50% align:middle
Jacqueline, "I actually want to
know what the acceptable process."
00:27:40.662 --> 00:27:43.882 position:50% align:middle
So I think what Jacqueline is asking
is another really good question.
00:27:43.882 --> 00:27:50.602 position:50% align:middle
It has to do with, again what I'm hoping to do next in
terms of my research and that is that critical
00:27:50.602 --> 00:27:58.122 position:50% align:middle
interface between organizational policies and practices
in the nurse who might be misusing and diverting.
00:27:58.122 --> 00:28:03.390 position:50% align:middle
And I really want to know for example,
if it's included in onboarding, orientation,
00:28:03.390 --> 00:28:07.610 position:50% align:middle
if it's a continuing ed type thing because we know that
it's a risk factor.
00:28:07.610 --> 00:28:13.930 position:50% align:middle
Those folks who are unaware of the influence,
if we can diminish that through education,
00:28:13.930 --> 00:28:14.980 position:50% align:middle
I think we should.
00:28:14.980 --> 00:28:16.070 position:50% align:middle
But there's a lot of...
00:28:16.070 --> 00:28:25.480 position:50% align:middle
I would direct your question to Monroe 2011, et al.,
and there's a a really robust discussion about the gaps
00:28:25.480 --> 00:28:30.515 position:50% align:middle
that we have in terms of understanding of the
organization and nurses interface,
00:28:30.515 --> 00:28:36.225 position:50% align:middle
and should report and how they
report suspected use from colleagues.
00:28:36.225 --> 00:28:37.665 position:50% align:middle
Hope that helps, Jacqueline.
00:28:37.665 --> 00:28:43.395 position:50% align:middle
Let's see.
So another question is from Mary.
00:28:43.395 --> 00:28:47.695 position:50% align:middle
"Did you access..."
We did...
00:28:47.695 --> 00:28:50.875 position:50% align:middle
So Mary's question has to do,
another really good question,
00:28:50.875 --> 00:28:56.265 position:50% align:middle
if we access to historical information about the
exposure of the nurses in our study to substance
00:28:56.265 --> 00:28:57.365 position:50% align:middle
abuse as children.
00:28:57.365 --> 00:29:05.718 position:50% align:middle
So the ACE, Adverse Childhood Experiences asks about
parental variables such as depression and mental
00:29:05.718 --> 00:29:07.538 position:50% align:middle
health issues, and substance use issues.
00:29:07.538 --> 00:29:11.408 position:50% align:middle
So that we didn't tease it out as a singular variable.
00:29:11.408 --> 00:29:16.028 position:50% align:middle
It was kind of lumped, the ACE score itself,
but we did track that.
00:29:16.028 --> 00:29:21.028 position:50% align:middle
And again you could see how ACE scores hopped up on
those regression models.
00:29:21.028 --> 00:29:22.564 position:50% align:middle
So we think it is...
00:29:22.564 --> 00:29:28.538 position:50% align:middle
And of course, there's familial tendencies we are
asking in some of our more current work,
00:29:28.764 --> 00:29:33.367 position:50% align:middle
do family members, do they have
a history of substance use.
00:29:33.367 --> 00:29:39.517 position:50% align:middle
So that is an important variable that we hope to kind
of tease out more specifically.
00:29:39.517 --> 00:29:42.277 position:50% align:middle
Let's see.
00:29:42.277 --> 00:29:48.183 position:50% align:middle
I think that might be all of it,
and I might be out of time. I don't know.
00:29:49.293 --> 00:29:51.225 position:50% align:middle
All right, thank you so much.