A Review of Substance Abuse Among Anesthesia Providers (PDF)

Journal of Research in Nursing 2019, Vol. 24(8) 587–600 A review of literature on...

Journal of Research in Nursing 2019, Vol. 24(8) 587–600 A review of literature on ! The Author(s) 2019 Article reuse guidelines: substance abuse among sagepub.com/journals-permissions DOI: 10.1177/1744987119827353 journals.sagepub.com/home/jrn anaesthesia providers Stephanie DeFord The University of Tennessee, USA Julie Bonom The University of Tennessee, USA Terri Durbin The University of Tennessee, USA Abstract Background: Research has demonstrated that anaesthesia providers are susceptible to substance abuse. Several preventive measures are being implemented in certified registered nurse anaesthetist programmes to educate future providers about substance abuse. Given the continued prevalence and impact of the problem, more research is needed about the prevalence of substance abuse among student registered nurse anaesthetists and the implementation of preventive strategies in the educational setting. Aims: The purpose of this narrative literature review was to examine the state of the science related to substance abuse among US certified anaesthesia providers. This literature review covered abuse of alcohol, tobacco, recreational drugs, opioids and anaesthetic agents. Methods: This narrative review was conducted using the following search terms: anaesthesia, student, wellness, stress, substance abuse, satisfaction, personality, depression, nurse, nurse anaesthetist, propofol, isoflurane and fentanyl. References were identified using PubMed, CINAHL, Google Scholar, and the American Society of Anesthesiologists and American Association of Nurse Anesthetists websites. A total of 36 articles were identified as relevant to this literature review based on content and country of publication. This literature review was limited to articles published in the past 15 years. With one exception, our search was limited to manuscripts from the US. Results: The literature underscored that various risk factors contribute to substance abuse. Board-certified anaesthesia providers fall prey to substance abuse due to ease of access, the high stress associated with administering anaesthesia, and the propensity to become addicted to opioids and other anaesthetics. A gap in the science exists about the prevalence of substance Corresponding author: Stephanie DeFord, The University of Tennessee, Knoxville, 1015 Hunts Lane, Hendersonville, TN 37075, USA. Email: [email protected] 588 Journal of Research in Nursing 24(8) abuse among student registered nurse anaesthetists and the effectiveness of preventive strategies in the educational setting. Conclusions: Anaesthesia providers are at high risk of abusing substances. To create a safer environment, future research should explore the prevalence of substance abuse among student registered nurse anaesthetists and emphasise the integration of effective preventive strategies in the educational setting. Keywords anaesthesia, depression, nurse, nurse anaesthetist, personality, satisfaction, stress, student, substance abuse, wellness Introduction With more than 41,000 practitioners in the United States (US) in 2016, certified registered nurse anaesthetists (CRNAs) are rapidly becoming the largest group of anaesthesia practitioners (United Nations (UN) Department of Labor, 2018). CRNAs practice with anaesthesiologists, dentists, surgeons and other physicians in a variety of settings. In addition, they often serve as the main anaesthesia practitioner in rural and military settings where they have a high level of autonomy. Due to the increasing number of CRNAs, physicians (anaesthesiologists) commonly supervise anaesthesia administration instead of doing it themselves (Dunn, 2010). According to the Bureau of Labor Statistics, the field of nurse anaesthesia is projected to grow by 16.2% between 2016 and 2026 resulting in approximately 48,600 CRNAs in 2026, (UN Department of Labor, 2018). The rapid growth in the field of nurse anaesthesia has increased the need to explore the safety of this group, specifically regarding substance abuse. Within the healthcare profession, substance abuse of alcohol, tobacco, recreational drugs and anaesthetic agents has become an increasingly widespread problem, with anaesthesia practitioners as the most common users (Baldisseri, 2007). While many CRNA schools are implementing substance abuse education programmes, this issue continues to threaten the safety of practitioners and their patients. The authors hypothesise that risk factors of substance abuse could and should be recognised and addressed in the educational setting. Therefore, we conducted a narrative review of literature in five areas: substance abuse prevalence, contributing factors, preventive measures, consequences of substance abuse, and re-entry into the field of anaesthesia following addiction. Prevalence Several studies have documented the fact that healthcare professionals are more at risk of substance abuse than are members of the public (Bell et al., 1999; Bozimowski et al., 2014; Luck and Hendrick, 2004). Among healthcare professionals, anaesthesia practitioners are particularly susceptible to addiction. According to a survey by Meeusen et al. (2010), substance abuse is the main occupational hazard of anaesthesia practitioners. While this study looked specifically at Dutch CRNAs, the data from the study can be generalised to other countries due to the large sample size, statistical significance and the similar DeFord et al. 589 personality attributes of CRNAs worldwide (Meeusen et al., 2010). Another study found that approximately 15% of these practitioners will abuse substances at some point in their careers (Valdes, 2014). Samuelson and Bryson (2016) found that anaesthesia providers are more likely to abuse drugs than alcohol. The abuse of opioids, ketamine, propofol (intravenous anaesthetic that potentiates the inhibitory effects of GABA), benzodiazepines and inhaled anaesthetic agents (volatile anaesthetics such as enflurane, isoflurane and halothane) is increasing in prevalence among anaesthesia providers (Bryson, 2018). Because of their high job stress and access to addictive substances, addiction is a growing threat to these healthcare practitioners. Students often turn to substance abuse for recreation and cognitive enhancement, while certified professionals seek substances for self-treatment or to improve job performance (Baldisseri, 2007). Because there is more abuse among licensed CRNAs than among student registered nurse anaesthetists (SRNAs), it is possible that SRNAs who refrain from substance abuse during their education may still fall prey to abuse and addiction at some time during their careers (Bozimowski et al., 2014). Substance abuse often begins after 10 years of practice (Valdes, 2014). To hide their addiction, anaesthesia practitioners often find creative ways to take drugs, such as injecting a drug between their fingers or putting it on their pillows. Because substance abuse can impair a practitioner’s ability to maintain constant vigilance during anaesthesia and to respond rapidly to changes in a patient, effectively addressing substance abuse within this field is essential to patient safety (Bell et al., 1999). As they go through school and begin to practice administering anaesthesia, anaesthesiologists and CRNAs often come to feel a sense of invulnerability to and control over substances and anaesthetic drugs (Valdes, 2014). This sense of invulnerability stems from the task of manipulating patient vital signs and neurological functions while handling highly addictive anaesthetics and opioids every day. Many anaesthesia providers feel they will not fall prey to addiction due to their knowledge of pharmacology (Samuelson and Bryson, 2016). The workplace is often the last place where substance abuse is recognised, while family and friends are often the first people to suspect addiction because they know the individual so well (Bryson and Silverstein, 2008; Wearing Masks, 2006). Samuelson and Bryson (2016) found that several healthcare professionals do not know how to identify or intervene with substance abuse among their co-workers. They are often in denial that their co-worker is abusing substances, and prefer to ignore the problem rather than ruining the impaired individual’s livelihood. By the time substance abuse is recognised, the addiction has likely progressed significantly, sometimes producing a fatal mishap for either the practitioner or the patient (Wright et al., 2012). Between 7 and 18% of physicians abusing substances will present with death or a nearly fatal overdose (Garcia-Guasch et al., 2012). The mortality rate of substance abuse among anaesthesia providers is 26–38% (Garcia-Guasch et al., 2012). Due to the high mortality rate following substance abuse, many preventive measures need to be in place to stop substance abuse from occurring and halt the progression of tolerance and addiction before someone dies. Contributing factors There are many risk factors for substance abuse among anaesthesia practitioners. The main contributing factors uncovered by this literature review were stress, job satisfaction, psychological disorders, personal and family history, and the nature of the job. 590 Journal of Research in Nursing 24(8) Stress In his literature review, Conner (2015) found that while stress can be a positive motivator, when stress levels become chronically high, negative outcomes follow. Chipas and colleagues (2012) conducted a qualitative, cross-sectional study in which a multifactorial, study-specific survey was sent to SRNAs across the US. This survey was a self-assessment questionnaire about various stress-related factors. The study found that the mean stress level of SRNAs is 7.2 out of 10 on a 10-point Likert scale. Stressors among this population include academic, clinical and outside factors, with information overload being the most prominent stressor. In addition, the results of Chipas et al. showed that stress is higher for students in programmes where clinical rotations occur throughout the programme than for students who complete clinical rotations after finishing didactic courses. Finally, stress was lower in students who exercised regularly. With a large sample size of 1282 SRNAs, the survey of Chipas et al. with students provides valuable insight into the stress that may contribute to post-education substance abuse (Chipas et al., 2012). Students in the competitive CRNA programmes often go from being the best in their class or specialty to being a beginner in the field of anaesthesia. Because CRNA schools are so challenging, many students quit their jobs, spend less time with family and friends, and move to a new area for their training (Conner, 2015). These factors all contribute to the students having higher levels of stress than both educators and CRNAs (Bryson, 2009). Chronic stress is worse than acute stress because it eventually leads to fatigue and burnout in the workforce (Chipas and McKenna, 2011). Job satisfaction Job satisfaction is another significant risk factor for substance abuse among anaesthesia practitioners. In a multifactorial questionnaire sent to both CRNAs and SRNAs, Chipas and McKenna (2011) found that the relationship between stress levels and job satisfaction contributes to certified practitioners being happier with their career choice than are students in nurse anaesthetist programmes. This study included a strong sample of 7537 participants with varied demographics. Based on the study’s statistical significance, Chipas and McKenna (2011) called for the implementation of standardised wellness improvement measures in the workplace to increase job satisfaction. Abbott et al. (2007) conducted a comparative study to examine workplace satisfaction among three CRNA groups: those employed at hospitals, anaesthesiologist groups and some other employer. The survey showed that, due to the number of high acuity and critical cases seen in hospital operating rooms, hospital-employed CRNAs are less satisfied with their jobs than are CRNAs working in clinics or other settings. Because this study only included CRNAs in Michigan, more research should be conducted with both SRNAs and CRNAs across the US. Two other factors, charge nurse leadership and social support from colleagues, also influence job satisfaction. Using the Myers–Briggs Type Indicator and the Big Five Model, Meeusen and colleagues (2010) found that employees who are extroverted, emotionally stable, orderly and easygoing are happier with their position in life. Anaesthesia practitioners who experience job burnout have a lower capacity to empathise with their patients, interact with their colleagues and care for themselves than do their colleagues who do not experience burnout (Ratanawongsa et al., 2008). The amount of DeFord et al. 591 time a provider has spent in the field of anaesthesia also presents as a risk factor for substance abuse. In their seminal work about substance abuse among CRNAs, Bell and colleagues (1999) found that CRNAs often do not abuse anaesthetics until they have spent approximately 10 years on the job. Of 167 survey participants who admitted to abusing controlled substances, 41.3% of CRNAs had been in practice for 6–10 years, while 21.6% of CRNAs had been in practice for 11–15 years (Bell et al., 1999). This delay in abuse may stem from the sense of invulnerability and advanced knowledge of pharmacology that comes from practising for several years (Samuelson and Bryson, 2016; Valdes, 2014). Psychological disorders Personality and underlying psychological disorders are risk factors for substance abuse (Bryson and Silverstein, 2008; Rose and Brown, 2010). Bell and colleagues (1999) suggested that eating disorders, sexual misconduct, alcohol abuse and uncontrolled drug use all could be predisposing factors that lead anaesthesia practitioners to abuse anaesthetics. Depression is common among healthcare professionals, who often fail to seek help for their psychological disorders. According to a study conducted by Rose and Brown (2010), due to the high stress levels of their jobs, anaesthesia practitioners are two to three times more susceptible to depression and suicide than the general public and other healthcare professionals. Using the NEO Personality Inventory (to measure impulsiveness, excitement seeking, and assertiveness) and the MacAndrew Scale (to measure addictive tendencies), McDonough (1990) examined the correlation between personality and addiction with a sample size of 81 SRNAs and 69 graduate nursing students. The author found that the typical substance abuser in the medical profession is the person who holds an advanced degree and works in a high-stress unit, such as the operating room. McDonough also found that anaesthesia students have a 22% tendency towards addiction, while Master’s of Nursing students have only a 5.9% tendency towards addiction. Because of the competitive nature of their jobs, anaesthesia practitioners are often high achievers with some degree of obsessive compulsive disorder. Such people are more susceptible to substance abuse because of their drive to succeed. Luck and Hedrick (2004) found that 66.7% of abusers were at the top of their classes. Sensation-seeking behaviours can also lead to substance abuse. While students often use substances recreationally, a practice that correlates with sensation-seeking behaviour, certified anaesthesia practitioners instead use substances to enhance their performance or for self-treatment (Baldisseri, 2007). According to Wright et al. (2014), the practitioner who recognises that a future of addiction could ruin their livelihood will be much less likely to abuse substances. Family and personal history Family history and previous substance abuse also contribute to substance abuse among anaesthesia practitioners. As with most diseases, addiction has a genetic component (Bozimowski et al., 2014). Luck and Hendrick (2004) found that men are often at a higher risk of substance abuse than women. Bell et al. (1999) mirrored this finding by showing that 62.9% of CRNAs who abuse substances are men. Previous addiction to substances such as alcohol has also been correlated with abuse of anaesthetics later in life (Wearing Masks, 2006). 592 Journal of Research in Nursing 24(8) The nature of the job Long hours and strong feelings of responsibility for patients make the job of anaesthesia provider a challenging one. Long shifts, night shifts, call shifts and repetitive work lead to fatigue and decrease the safety of both patients and healthcare practitioners (Neft and Greenier, 2013). Fatigue contributes to substance abuse as anaesthesia practitioners turn to narcotics or other drugs to help improve their performance (Aichmuller ¨ and Soyka, 2015). Methods to help alleviate or prevent fatigue include delegating tasks to others or finding ways to stay busy such as reading or talking (Domen et al., 2015; Valdes, 2014). Stress and intense work demands can also lead to errors in administering anaesthesia. Finally, critical events, such as operating room deaths or near mishaps, often lead to substance abuse by anaesthesia practitioners as they try to deal with such occurrences (American Association of Nurse Anesthetists (AANA), n.d.). Besides predisposing anaesthesia providers to substance abuse, critical events can also lead to depression, fatigue and many other symptoms. Preventive measures Many programmes are already in place to prevent abuse of both licit and illicit substances in educational and occupational settings. Other specific strategies are used to deter previous addicts from abusing substances again. Through a review of the literature, Wright et al. (2014) stressed that the foundation for all preventive measures is the individual’s desire to recover from previous substance abuse and never to abuse substances again. Without this attitude, preventive measures are useless. The main measures uncovered in this literature review were wellness education, substance tracking, substance abuse education, peer support, relapse deterrence and fatigue prevention. Wellness education After conducting interviews with 26 medical residents from various specialties, Ratanawongsa and colleagues (2008) found that students defined wellness as a balance between their social and professional lives. Lack of wellbeing can lead to conflict with co-workers, mistakes in the workplace, and career choice dissatisfaction. While the results of this study can likely be applied to SRNAs and CRNAs, the small sample size and inclusion of residents from specialties other than anaesthesia make the generalisability hard to determine. As personal wellness and professional satisfaction are so closely intertwined, many anaesthesia schools have incorporated wellness education into their curriculum (Bozimowski et al., 2014). Many nurse anaesthetist students have requested that wellness or exercise programmes be incorporated into their education as part of a class because they often do not find time to participate in such activities on their own (Bozimowski et al., 2014; Chipas et al., 2012). These wellness programmes could help students reach their full potential in the medical field and help keep them safe from substance abuse (Ratanawongsa et al., 2008). One group of students also indicated that they wanted more wellness education in school, a finding indicating that current education on this topic was not sufficient (Chipas and McKenna, 2011). Substance tracking In a literature review examining opioid abuse and dependency among CRNAs and anaesthesiologists, Wright et al. (2012) emphasised that the evolution of computerised charting DeFord et al. 593 and medication distribution has helped to curb substance abuse by holding practitioners more accountable for the drugs they administer. These computerised programmes check for excessive drug waste, people taking opioids and anaesthetics after a case is finished, or discrepancies in the amount of drug used (Tetzlaff et al., 2010). The American Society of Anesthesiologists (ASA) recommends that pharmacies test the contents of wasted drug syringes to ensure that all controlled substances are accounted for (ASA, n.d.). The ASA also encourages clinical facilities to monitor medication administration records for any discrepancies in the amount of drug used (ASA, n.d.). Control of the anaesthetic drug supply is the most effective preventive measure currently used by hospitals (Bryson and Silverstein, 2008). While computerised charting and regulated medication distribution has made a great deal of progress in preventing substance abuse, Stocks’ study about the abuse of propofol (a non- controlled substance) has highlighted the need to keep all narcotics in locked storage, even if they are not considered controlled or high-risk substances (Stocks, 2011). As abuse of anaesthetics is often precipitated by abuse of other drugs, such a measure could help improve the success of regulated medication distribution. Substance abuse education Samuelson and Bryson (2016) found that many individuals are not able to recognise substance abuse among their co-workers. Because tolerance and addiction to anaesthetic agents occur rapidly, it is critical that everyone on an anaesthesia unit be able to recognise the signs and symptoms of substance abuse. The AANA provides a list of common signs and symptoms to look for when suspecting substance abuse (AANA, 2016). These signs and symptoms include lower exam scores during residency, spending more time at the hospital, refusing breaks from their case, and signing out excessive amounts of drugs (Samuelson and Bryson, 2016). While Samuelson and Bryson focused on medical doctors, their findings can be extrapolated to nurse anaesthetists. Nurse anaesthesia and medical schools should adopt a universal educational standard for substance abuse instruction (Baldisseri, 2007; Wearing Masks, 2006). Improved educational programmes both in schools and in the workplace need to educate students and practitioners about the prevalence of substance abuse in anaesthesia, how to prevent the problem, and safe ways to deal with addiction (Luck and Hendrick, 2004). Boulton and Nosek (2014) conducted a quasi-experimental study with a two-group, pre-test–post-test design. Using the perception of nurse impairment inventory, they asked 67 sophomore and 33 junior undergraduate nursing students about their perceptions of substance abuse in the nursing profession. After providing the junior nursing students with substance abuse education, the questionnaire was filled out again by all participants. The study showed that most students did not think substance abuse was a problem in nursing, even after the education. While this study included only undergraduate nursing students, its results highlight the need to educate other healthcare employees about substance abuse so they can help prevent it and catch it early. One of the main educational tools used for both nurse anaesthetists and anaesthesiologists is the video series entitled Wearing Masks: The Potential for Drug Addiction in Anesthesia (see Bryson and Silverstein, 2008; Rose and Brown, 2010). Produced in 1993, this series contains information on the common signs and symptoms of substance abuse, some of the risk factors that lead anaesthesia practitioners to abuse drugs, and the overall prevalence of substance abuse within this field. In addition to addressing the 594 Journal of Research in Nursing 24(8) abuse of anaesthetic agents, this series also covers addiction to alcohol and other chemicals, such as marijuana and illicit substances. The overall goal of the series is to educate anaesthesia practitioners about the prevalence and consequences of substance abuse. In 2006, Wearing Masks II: The Potential for Drug Addiction in Anesthesia was developed. This series focuses on educating the families and co-workers of anaesthesia providers on the signs and symptoms of substance abuse, how to catch abuse early and how to help the impaired individual (AANA, 2018). The makers of the series recognise that in order to stop substance abuse before an injury or fatality occurs in the workplace, everyone on an anaesthesia unit needs to be alert for signs and symptoms (Wearing Masks, 2006). Both series of Wearing Masks can be found on the AANA website and are among the current preventive measures supported by the AANA. In a report of the early detection methods used at a particular institute, Tetzlaff et al. (2010) found that providing continuing education for all anaesthesia practitioners and the employees who work with them has curbed substance abuse. This programme (the SAPP project), which trains all staff members to recognise addiction, has worked to prevent substance abuse and detect it early. More research needs to be done to determine whether the SAPP project could be successful at other institutions. Peer support Studies have found that peer support and discussion programmes have been helpful in preventing substance abuse and supporting those dealing with addiction (Quinlan, 2009; Wright et al., 2012). The AANA (2016) website provides a peer assistance helpline that nurse anaesthetists can reach out to as needed. As mentioned previously, many healthcare professionals deal with depression and excessively high stress levels due to the nature of their jobs. Therefore, some institutions have established discussion groups for employees working in operating rooms, intensive care units and emergency rooms. In these settings, the employees can talk to their peers about topics such as depression, stress and critical events. Some hospitals have started screening employees for depression so that it may be identified and treated early (Rose and Brown, 2010). The need for more social support and peer programmes has been expressed by participants in several studies (Boulton and Nosek, 2014; Conner, 2015; Rose and Brown, 2010). In their synthesis of papers related to substance abuse policies in the nursing profession, Monroe and Kenaga (2011) emphasised the need for early recognition, intervention and treatment of substance abuse. Studies have shown that timely identification and treatment of substance abuse is essential for helping the practitioner and increasing patient safety (Baldiseri, 2007; Monroe and Kenaga, 2011; Quinlan, 2009). Practitioners also need a safe space where they can talk about these issues with people who understand what they are going through. While Monroe and Kenaga’s (2011) literature review on peer support focused on nurses in general, the implications can be extrapolated to anaesthesia practitioners. While some institutions offer peer discussion programmes, there appears to be a need for such programmes to become a universal standard. Anaesthesia practitioners receiving more support from their families and friends also could aid in the early recognition and treatment of substance abuse. A study by Bryson and Silverstein (2008) showed that families and friends are often the first people to suspect addiction due to their close relationship with the impaired individual. The AANA suggests that the video series Wearing Masks: The Potential for Drug Addiction in Anesthesia should DeFord et al. 595 be shown to the friends and family members of nurse anaesthesia students because they believe that the home is the first place where substance abuse can be recognised and stopped (see Wright et al., 2014). Therefore, it would be beneficial to educate family and friends on the signs of substance abuse. Fatigue prevention Because provider fatigue can promote substance abuse and affect patient care, the AANA implemented several policies to prevent CRNA fatigue including requiring nurses to take a break from administering anaesthesia after working 16 consecutive hours. In addition, the AANA has recommended that nurse anaesthetists receive education about fatigue-related issues such as sleep deprivation, circadian rhythms, light therapy and caffeine use (Neft and Greenier, 2013). Consequences The significance of substance abuse among anaesthesia providers includes personal, professional and legal consequences. Bryson (2018) expanded on the personal consequences of substance abuse by anaesthesiologists, which includes failure to complete residency or to become board-certified and loss of medical licensure. Even after attending rehabilitation, many anaesthesia providers fail to find employment due to the stigma of addiction and risk of relapse (Samuelson and Bryson, 2016). The most serious personal consequence of substance abuse is death of a patient or the provider (Bryson, 2018). Legal and financial consequences to the impaired provider and facility of employment arise through law suits by patients involved in cases of anaesthesia administered under dangerous circumstances (Rice et al., 2017). The AANA outlines the need to maintain the privacy of the impaired anaesthesia provider while still reporting the provider to the state board of nursing. Most states allow providers to enter a rehabilitation facility rather than undergo disciplinary action (AANA, 2016). The ASA (n.d.) requires enrollment in treatment programmes specific to anaesthesia providers and participation in the Physician’s Health Service recovery plan. After being recognised as having a substance abuse problem, both CRNAs and students are more likely than physicians to have their licenses revoked or to be forced into another specialty (Luck and Hedrick, 2004; Valdes, 2014). Valdes (2014) called for giving CRNAs, like physicians, a non-punitive way to turn themselves in and seek help. If there was a non-public way for healthcare professionals to deal with addiction, they would be more likely to seek help (Quinlan, 2009). Unfortunately, due to shame or fear, many anaesthesia practitioners cause harm to themselves or their patients before seeking help (Monroe and Kenaga, 2011). Re-entry and relapse prevention Several state regulatory bodies allow previously impaired anaesthesia providers to re-enter the clinical setting under specific circumstances. Because the risk of relapse is so high, careful assessment of each case should be carried out before allowing an anaesthesia provider into the clinical setting again (Samuelson and Bryson, 2016). Guidelines have been instituted by programmes across the country to aid in successful re-entry and prevention of relapse by previously impaired anaesthesia providers. 596 Journal of Research in Nursing 24(8) Re-entry into the workplace The AANA has outlined guidelines for re-entry of the impaired provider into the clinical setting. The AANA suggests that previously impaired providers be in recovery for a minimum of 1 year before engaging in anaesthesia administration again. These anaesthesia providers should ease back into work with minimal call and overtime opportunities (AANA, 2016). Returning anaesthesia providers should abstain from all substances including, but not limited to, alcohol, tobacco, cannabis, opioids and anaesthetics. They should be treated for psychiatric co-morbidities, attend group psychotherapy and participate in a 12-step programme such as Alcoholics Anonymous or Narcotics Anonymous (AANA, 2016; Samuelson and Bryson, 2016). In addition to these guidelines, the AANA suggests that providers be monitored by a supervisor in addition to the state board of nursing (AANA, 2016). Relapse deterrence Previous substance abuse with anaesthetics plays a significant role in addiction, as these individuals are at very high risk of relapse or even death when permitted to re-enter the anaesthesia field. Bryson (2009) sent a survey to 131 directors of anaesthesia residency programmes across the US to assess their opinions on allowing previous substance abusers to practise again. With a response from 91 programme directors, Bryson determined that re-entry into practice often leads to relapse if the addiction is not dealt with in a timely and effective manner. This study only surveyed medical doctors, so a similar survey sent to CRNAs would be useful for this area of research. Some studies have shown that 25–56% of practitioners will relapse if allowed to administer anaesthesia again (Bozimowski et al., 2014; Valdes, 2014). Rejection by peers is a major concern for healthcare professionals returning to work after going through addiction, and one that makes it harder for them to communicate to their co-workers about their stress and needs (Bozimowski et al., 2014). Because relapse is so common, precautions should be taken before allowing someone back into the workforce. In their literature review, Bozimowski et al. (2014) found that many schools and workplaces hold anaesthesia practitioners accountable, using random drug testing. Wright et al. (2014) found that one of the best ways to help practitioners who are resuming anaesthesia administration after dealing with addiction is simply allowing them adequate time away from the practice. In addition, providers who have dealt with addiction are often required to sign strict contracts to prevent future substance abuse (Luck and Hedrick, 2004). Valdes (2014) used Walker and Avant’s concept analysis model to examine various case studies related to substance abuse and workplace re- entry. The author identified completion of addiction rehabilitation programmes, support groups, re-entry contracts and random drug screenings as essential factors for successful re-entry into anaesthesia practice. While Valdes’ study provided insight into both the prevention and treatment of substance abuse, more research needs to be conducted about the distinct needs and characteristics of CRNAs versus those of anaesthesiologists. Conclusions The demand for anaesthesia practitioners continues to be high, while the availability of anaesthesiologists is low due to the time and money required to train them. Therefore, DeFord et al. 597 CRNAs have become the largest group of anaesthesia providers in the US, especially in rural and military sites. Due to various risk factors, substance abuse of both licit and illicit substances continues to be one of the main occupational hazards of anaesthesia practitioners. Stress, job satisfaction, psychological disorders, family and personal history, and the nature of the job all contribute to substance abuse among anaesthesia providers. Current measures to prevent substance abuse include wellness education, substance tracking, substance abuse education, peer support and fatigue prevention. The consequences of substance abuse range from legal consequences, such as loss of licence, to personal consequences, such as death. Re-entry into the field of anaesthesia is possible for previously impaired anaesthesia providers, but the risk of relapse is high. Due to the prevalence of substance abuse among anaesthesia providers and the severity of the consequences to both patients and providers, more measures need to be implemented in order to prevent and halt the progression of substance abuse within this field. Suggestions to improve practice The articles included in this literature review provide suggestions for reducing factors that contribute to substance abuse, improving preventive measures, changes to the consequences of substance abuse, and ways to improve the success rates of re-entry into the field of anaesthesia. Suggestions for practitioners, educators, employers and policy makers are outlined in Figure 1. The authors propose that additional changes be implemented as well as those outlined above. These include reducing the number of 16-hour shifts worked by anaesthesia providers, changing propofol to a controlled substance, and evaluating and updating the video series Wearing Masks. Literature gap and implications for further research As outlined in the literature, many improvements still need to be made in measures to prevent substance abuse among anaesthesia practitioners in educational and workplace settings. However, most of the studies focused on substance abuse among registered practitioners rather than in students, specifically SRNAs. The growing population of nurse anaesthetists comes from a growing number of students in anaesthesia programmes. This growth should emphasise the urgency to investigate ways to encourage students to adopt healthy stress management techniques before they graduate to prevent them from abusing substances after they go into practice. The literature results indicate that more research is needed to investigate substance abuse and the effectiveness of current preventive measures from the SRNA perspective. Because substance abuse is more common in CRNAs than in SRNAs, talking to anaesthetists who have experienced addiction could promote a better understanding about why they started abusing substances, and how to address the issues among students. The educational period is a formative time that shapes the rest of an anaesthesia practitioner’s career. Therefore, addressing substance abuse issues during this period could be an optimal way to improve preventive measures. Along with investigating student perceptions of substance abuse, further research should also focus on preventive measures at the educational level to determine which measures are successful, which are unsuccessful, and what methods could be employed to decrease the 598 Journal of Research in Nursing 24(8) Contributing factors Standardise wellness improvement measures (Chipas and McKenna, 2011) Decrease stress via delegation (Domen et al., 2015; Valdes, 2014) Preventive measures Keep all narcotics in locked storage (Stocks, 2011) Universal educational standard for substance abuse education (Boulton and Nosek, 2014) Implement peer discussion programmes as a universal standard in clinical settings (Boulton and Nosek, 2014; Conner, 2015; Monroe and Kenaga, 2011; Rose and Brown, 2010) Show the video series Wearing Masks: The Potential for Drug Addiction in Anesthesia to family and friends (Wright et al., 2014) Consequences Non-punitive methods for physicians, CRNAs and students to seek help (Quinlan, 2009; Valdes, 2014) Maintain privacy of impaired provider while still reporting to the state board of nursing (Addressing Substance Use Disorder for Anesthesia Professionals) Reentry and relapse Abstinence from all substances (Sameulson and Bryson, 2016) Monitoring by supervisor (Addressing Substance Use Disorder for Anesthesia Professionals) Figure 1. Methods to Improve Safety and Practice for Anesthesia Providers. prevalence of substance abuse. In order to prevent students from abusing substances in the future, they need to be given the tools to recognise, prevent and address the substance abuse issues that may arise during their careers. The current level of substance abuse among anaesthesia practitioners indicates that this objective is not being accomplished in anaesthesia programmes. As stated previously, most CRNAs do not abuse substances until 10 years into practice (Bell et al., 1999). Therefore, the importance of having a standardised educational tool to teach students about substance abuse before they begin their careers is imperative. Finding ways to improve measures to prevent substance abuse among anaesthesia providers will make the practice environment a safer place for both healthcare professionals and their patients. Key points for policy, practice and/or research. Some suggestions to improve practice include standardising wellness improvement measures, implementing peer discussion programmes in the clinical setting, establishing non-punitive methods for anaesthesia providers to seek help, and supervising re-entry into the field of anaesthesia after addiction.. More research is needed to investigate substance abuse and the effectiveness of current preventive measures from the SRNA perspective.. SRNAs should be taught to recognise, prevent and address substance abuse issues in the workplace.. A standardised educational tool should be developed to teach students about substance abuse. DeFord et al. 599 Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Ethics Ethical permissions were not needed in this study as this is a literature review. 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