Preceptions Chemically Impaired nursing

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REGISTERED NURSES’ PERCEPTIONS OF WORKING WITH CHEMICALLY
IMPAIRED REGISTERED NURSE COLLEAGUES
by
Kimberly S. Esquibel

REBA GLIDEWELL, Ph.D., Faculty Mentor and Chair
SHARLENE ADAMS, PsyD, Committee Member
BEVERLY GOODWIN, Ph.D., Committee Member

Deborah Bushway, Ph.D., Dean, Harold Abel School of Psychology


A Dissertation Presented in Partial Fulfillment
Of the Requirements for the Degree
Doctor of Philosophy


Capella University
J uly 2009







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UMI Number: 3360070


Copyright 2009 by
Esquibel, Kimberly S.


All rights reserved




INFORMATION TO USERS


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© Kimberly S. Esquibel, 2009








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Abstract
Although many studies have been conducted to learn more about the experiences
of chemically impaired nurses, few studies have attempted to describe the experiences
and perceptions of nurses who work with impaired colleagues as a discreet population.
Guided by King’s (1981, 1996) theoretical framework, this qualitative, phenomenological
study explored the perceptions of 12 registered nurses working with a chemically
impaired registered nurse colleague as a personal lived experience. Each member of the
purposefully selected sample participated in an audio-taped, open-ended interview with
the researcher. The interviews followed a guide developed by the researcher. The data
was analyzed according to Colaizzi’s (1978) procedural steps. Five major themes
emerged which were centered on the influence of personal values, professional impact, a
culture of silence and denial, lack of education, and a professional stigma and
stereotypical views. The findings of the study reflect the overall need for educating
nurses about the addictive disease process, workplace policies on addiction and
treatment, peer assistance programs including personnel with knowledge of addictions,
training in interventions, and awareness of referral options and availability of resources to
help support nurses’ recovery from addictions. This study will add to the current body of
the professional literature. Also, the previous lack of scholarly exploration in the area of
colleagues who work with impaired nurses may propagate future qualitative inquiry.








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Dedication
This dissertation is dedicated to the many nurses who struggle with chemical impairment
and to the colleagues who struggle to help them. I extend my prayers to all of you who
seek freedom from chemical impairment and to those who can help you to reach that
goal. I wish you Godspeed.







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Acknowledgments
I extend warmest appreciation and respect to Dr. Reba Glidewell, my Capella
mentor and committee chair. Her calm, enthusiastic support and unyielding guidance
encouraged me throughout my Capella dissertation process. Her commitment to and faith
in both this study and me inspired the ideas, energy, and perspective that went into this
dissertation project. It has been an honor and privilege to work with you. I would also
like to thank Dr. Sharlene Adams and Dr. Beverly Goodwin for their work as instructors
and willingness to be on my dissertation committee.
I wish to extend my deepest thanks to the research participants who so generously
gave of their time to share their personal stories and experiences. I am eternally grateful
for your candor and courage to speak of your experiences, and thank you for providing
me with the rich experience of sharing your stories. Your stories truly made my study
come to life.
I would also like to thank those closest to me. To my mom who has been a source
of light and encouragement, teaching me perseverance and patience throughout my life;
my dad who taught me about setting goals and creating opportunities; and my brothers,
who have taught me about seeing the lighter side of life and remembering to laugh. To
John who has been by my side throughout my journey. I thank you for your endless
encouragement, love, and teaching me to believe in myself. To my canine friends, Max
and Scooter, you spent countless hours lying at my feet while I worked at the computer.
And finally, I wish to thank my son Brendon who is the greatest source of joy in
my life. You have provided me with the encouragement to complete my Ph.D. You are
my source of strength and I love you more than words can say.







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Table of Contents

Acknowledgments iv
List of Tables viii
CHAPTER 1: INTRODUCTION 1
Introduction to the Problem 1
Background of the Study 3
Statement of the Problem 4
Purpose of the Study 6
Rationale 7
Research Questions 7
Significance of the Study 9
Definition of Terms 10
Assumptions 13
Limitations 14
Nature of the Study 15
Theoretical/Conceptual Framework 16
Organization of the Remainder of the Study 22
CHAPTER 2: LITERATURE REVIEW 24
Chemical Misuse and Impairment in Nursing 24
Recognizing Signs of Chemical Impairment 29
Recognizing Signs of Drug Diversion 31
Obstacles to Identification and Early Reporting of Chemically Impaired Nurses 32







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Reporting Behaviors of Colleagues 41
Attitudes toward Impaired Nurse Colleagues 44
Legal and Ethical Considerations of Impaired Nurse Practice 47
Application of King’s Theory of Goal Attainment Within this Study 49
Summary 50
CHAPTER 3: METHODOLOGY 52
Purpose of the Study 52
Research Design 53
Methods 55
Procedures 59
Expected Findings 78
CHAPTER 4: DATA COLLECTION AND ANALYSIS 81
Introduction 81
Description of the Sample 82
Research Methodology Applied to the Data Analysis 84
Presentation of Data and Results of Analysis 85
Research Question 1 86
Research Question 2 99
Research Question 3 103
Research Question 4 117
Research Question 5 128
Research Question 6 132
Presentation of Major Themes in Data Analysis 139







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Essence 150
Validity and Reliability 151
Summary 151
CHAPTER 5: RESULTS, CONCLUSIONS, AND RECOMMENDATIONS 153
Introduction 153
Summary of the Results 153
Discussion of the Results 155
Discussion of the Conclusions 170
Limitations to the Study 181
Implications for the Field of Psychology and Nursing 182
Recommendations for Further Research 185
Conclusion 186
REFERENCES 188
APPENDIX A: PARTICIPANT DEMOGRAPHIC HISTORY FORM 199

APPENDIX B: INTERVIEW QUESTIONS 202









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List of Tables

Table 1: Correlation of Sub-themes Highlighting the Perceptions of the
Participants with King’s (1996) Concepts within the Personal System 162

Table 2: Correlation of Sub-themes Highlighting the Perceptions of the
Participants with King’s (1996) Concepts within the Interpersonal System 165

Table 3: Correlation of Sub-themes Highlighting the Perceptions of the
Participants with King’s (1996) Concepts within the Social System 168










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CHAPTER 1: INTRODUCTION

Introduction to the Problem
The problem of chemical abuse and dependency crosses all boundaries, including
gender, race, culture, age, and class (Sheehan, 1992). Abuse of chemical substances,
either alcohol and/or other mood altering drugs, is a major health problem that negatively
affects the lives of millions of Americans. Nearly 20 million adults in the United States
are problem drinkers, and 14 million of them suffer from alcoholism (National Institute
on Alcohol Abuse and Alcoholism, 2000). An additional four million individuals are
believed to be drug abusers. Two million of these individuals are considered to be non-
narcotic drug abusers and three million are considered to be narcotic drug abusers
(National Institute on Drug Abuse, 1999).
The workplace is not immune to chemical abuse and dependency problems.
Studies show that at least 1 of every 10 American workers use illegal drugs on the job
(Brice, 1990; Galvin, 2000). Any job performed in an impaired condition constitutes
some risk or loss to society (Galvin, 2000; Sullivan, Bissell, & Williams, 1988).
The problem is even more significant in the health care professions. Coombs
(1997) found that drug abuse is at least as prevalent among highly regarded professionals
(physicians and other health care professionals) as among the general public. McAuliffe
et al. (1986) reported that 59% of physicians had used psychoactive drugs in their lives;
while one in four had abused prescription drugs and one in ten were projected to use
drugs regularly during their career. By the middle of the 1990s, over 60,000 registered







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nurses were thought to be alcoholic and somewhere between two and four percent were
thought to be addicted to drugs (Trinkoff & Storr, 1998). Today, eight to 10 percent of
the 2.2 million registered nurses in the United States are estimated to have chemical
addiction problems (Copp, 2009; Snow & Hughes, 2003; Stammer, 2007).
Despite their professional education, nurses are not immune to chemical
dependency. Often the disease is severe by the time their work is affected (Fink,
Hickman, & Miller, 1993; Quinlan, 2003). Nurses, who practice while impaired, place
their patients, colleagues, themselves, and the entire health care community at risk. The
threat to patient welfare posed by impaired nursing through substandard care and possible
diversion of medication is a matter of genuine concern (Snow & Tipton, 2006).
As a health care profession, nursing accepts the disease definition of addiction
and has made an effort to work toward its prevention and treatment, both among the
general population and within its own ranks (Naegle, 2003). Problems related to
substance abuse unfortunately often do not arise until the problem has reached a serious
level. Usually by the time a nurse is confronted with a substance abuse problem, most of
his or her colleagues were already aware of the problem but had not said anything about
it (Taylor, 2003).
One phenomenon that surfaces in the literature is a delay in occupational
reporting for substance abuse treatment (Gossop, Stephens, Duncan, Marshall, Bearn, &
Strang, 2001; Huton, 2005; Weiss, 2005). But while there is scholarly consensus that
delays exists minimal research has been conducted on the reasons for such delays; and no
one has studied the reasons that nurses delay or do not report chemically impaired nurse
colleagues. Thus, research is needed to determine why some nurses with substance abuse







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problems are not being adequately identified by their nurse colleagues and referred for
treatment in a timely fashion. Research in this area may assist nurse colleagues to more
efficiently identify chemical abuse and abusers to speed up the referral process.
Understanding registered nurses’ perceptions of working with chemically impaired
colleagues as a personal lived experience might help to illuminate how the process could
improve.

Background of the Study
The problem of nurses with substance-related disorders is not new. The problem
gained an increased awareness in the early 1980s when the American Nurses Association
(ANA) (1984) defined an impaired nurse as “one who, as the result of alcohol and drug
abuse, has difficulty functioning in the nurse role” (p. 18). This, in turn, interferes with
their ability to provide safe, effective care. The period of the late 1980s into the 1990s
saw the emergence of formal research on addiction and substance use in nursing with a
focus on risk factors, attitudes about, effects, and consequences of impairment. Little
attention has been given to early identification of chemically impaired nurses, early
reporting, and interventions to assist nurses to recognize impaired nurse colleagues. In the
last ten years research has focused on treatment and re-entry into practice.
A positive step was made in 1992 when the American Association of Colleges of
Nursing (AACN) created a Substance Abuse Task Force. The task force was charged
with developing a policy statement to address the problem of substance abuse in the
nursing community. The task force recognized that substance abuse is a universal health
problem that affects all segments of society and that substance abuse is a major issue for







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nursing students, faculty, and staff. The general assumptions and principles used by the
task force in developing policies and guidelines emphasized that substance abuse in
nursing education must be addressed, but most of the assumptions focused on risk
factors, monitoring of nurses with substance abuse problems, rehabilitation, and re-entry
into practice. Again, very little emphasis was given to early identification and reporting
of substance impaired nurses. In a position statement by the task force, only two
paragraphs addressed education and early identification (AACN, 1996). The majority of
the research literature found was published in the 1980s and late 1990s. Most studies
published in the last 8 years address the chemically dependent nurse.
Having worked with nurses, who practiced while impaired by chemical
substances, initially sparked my interest to learn more about this phenomenon. In
reviewing the literature it became increasingly evident that little attention has been given
to registered nurses’ perceptions of impaired nurse colleagues as a personal lived
experience. Specifically, why do some nurses report impaired colleagues and others do
not? What experiences do nurses go through in making the decision to report, not report,
or delay reporting a chemically impaired nurse colleague? Do nurses’ perceptions of their
colleagues affect their decision to report? Miller (1997) indicates that nurses themselves
are in the best position to identify changes or problems in their colleague’s nursing
practice.

Statement of the Problem
Chemical impairment in nurses is a prevalent and serious problem yet little has
been published that describes the actual perceptions of registered nurses toward







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chemically impaired nurse colleagues as a personal lived experience. Many qualitative
studies have been conducted in order to learn more about the experiences of the
chemically impaired nurse from a variety of perspectives. For example, studies have
described the experiences of nurses being labeled chemically impaired (Brewer & Nelms,
1998; Lillibridge, Cox, & Cross, 2002), described the experiences of recovering nurses’
re-entry to practice (Hughes, Smith, & Howard, 1998), and described attitudes and
perceptions of chemically impaired nurses’ experiences with chemical misuse (Shaffer,
1988; Tariman, 2007). In addition, Wennerstrom and Rooda (1996) studied attitudes and
perceptions of nursing students toward chemically impaired nurses while Smith (1992)
studied attitudes and perceptions of nurse managers and assistant nurse managers toward
chemically impaired colleagues. However, few, if any, studies have attempted to describe
registered nurses’ perceptions of impaired registered nurse colleagues as a personal lived
experience.
Fellow nurses of those with a substance abuse problem have an ethical and legal
obligation to report a colleague whose activities could result in harm to a patient.
Remaining silent about a colleague’s suspected problem violates a nurse’s ethical duty to
safe-guard patient care. According to the ANA (2003), nurses are responsible for
responding when a colleague is exhibiting questionable actions or practices by reporting
suspicions to the appropriate personnel as an advocate to the patient.
Another reason for reporting a colleague’s substance abuse, beyond patient
advocacy, is to help the nurse at risk. Reporting nurses with an addiction could save their
lives and help them to keep their profession after they obtain treatment. Friendship and
loyalty among the nursing community often makes it easier for colleagues to look the







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other way at suspicious behavior and deny that there is a problem (Smith, Taylor, &
Hughes, 1998).
In one study, 91% of respondents stated they would report an incident by an
impaired colleague that either harmed patients or put them at risk for harm. In actuality,
only about half that number reported incidents that they witnessed that possibly put a
patient at risk for harm (Taylor, 2003). It is also presumed that many nurses react
negatively to their peers who abuse substances (Brewer & Nelms, 1998; Burke, 1999;
Hendrix, Sabritt, McDaniel, & Field, 1987). Thus, nurses who become addicted might be
more likely to feel shame and experience guilt, which can also delay treatment and
recovery. The lack of collegial response, as well as insufficient education, may also play
a major role in the late identification of peers with addiction problems.

Purpose of the Study
The purpose of this study was to discover and interpret registered nurses’
perceptions of impaired nurse colleagues as a personal lived experience. The study used a
qualitative, phenomenological approach. Through a comprehensive analysis of
transcribed interviews, demographic sheets, and field notes, I was able to understand the
lives of the participants as related to their perceptions of working with impaired nurse
colleagues. Ultimately, the focus of this study was to identify the needs of registered
nurses who work with impaired nurse colleagues as related to early identification and
reporting.









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Rationale
Gaining insight into registered nurses’ perceptions toward impaired nurse
colleagues is crucial because many may not recognize chemically impaired colleagues
and may dismiss unusual or inappropriate behavior as simply responses to a temporary
crisis, problems at home, frustration with the job, fatigue, and physical problems that may
warrant medical treatment. These problems provide a rationale for a colleague’s changes
in behavior and job performance. The subtle signs of substance abuse may be dismissed
as nothing out of the ordinary. Furthermore, enabling behavior is common among the
colleagues of substance abusing nurses (Pullen & Green, 1997). Enabling occurs when a
harmfully involved person is protected from the full negative consequences of their use.
Although well intentioned, enabling behavior is a serious obstacle to dealing with the
problem of substance abuse. If nurses are unaware of what is going on, they may actually
enable impaired nurses with behaviors such as covering for them. By gaining an
understanding of registered nurses’ perceptions of impaired nurse colleagues, appropriate
education and earlier identification and reporting may result. The primary aim of this
study was to gain insight into registered nurses’ perceptions of working with impaired
nurse colleagues. The goal was to identify ways to improve the identification of and early
reporting of impaired practice.

Research Questions
In this study I attempted to describe registered nurses’ experiences of working
with impaired nurse colleagues and their perceptions toward these colleagues. Further, I
sought to determine whether their perceptions affected their experience. My previous







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readings and study on the subject of chemically impaired nurses, King’s (1996) theory of
goal attainment, along with the purpose of the study, were the primary guides in the
development of the guided questions participants were asked.
The qualitative nature of this study carried with it the underlying belief that a
single, ultimate truth did not exist (Guba & Lincoln, 1989). It was believed that multiple
perspectives of the same phenomena may be held by different participants, each having
comparatively equal authority (Leedy & Ormrod, 2005). As such, the following questions
guided the study:
1. What types of experiences have nurses encountered with a chemically impaired
colleague in the workplace?
2. How do nurses perceive colleagues who practiced while chemically impaired?
3. How did nurses react to their chemically impaired colleagues?
4. What factors in nurses’ personal system influenced their perceptions of and
reactions to their chemically impaired colleagues?
5. What factors in nurses’ interpersonal system influenced their perceptions of and
reactions to their chemically impaired colleagues?
6. What factors in nurses’ social system influenced their perceptions of and reactions
to their chemically impaired colleagues?
The research questions were related to the research problem as they were broad in
nature and allowed for a variety of themes to emerge from the responses given by
participants. The questions were also related to the major concept in this study, the
phenomenon of chemically impaired nurse colleagues from the perspective of registered
nurses who worked with them. Analysis of the data sought to answer these questions.







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Significance of the Study
This study is important to psychologists who work with nursing staff in hospitals,
to substance abuse therapists in general, and to the field of psychology as a whole. The
significance to the field of psychology includes an increased understanding of the
complexities of personal, interpersonal, and social systems as nurses perceive and
describe their experiences of working with impaired nurse colleagues. As a result, it may
provide valuable information for implementing substance abuse education, early
identification, and early reporting programs to assist nurses.
Although the literature describes the typical chemically impaired nurse (Bissell &
Jones, 1981; Bugle, 1996; Finke, Hickman, & Miller, 1993; Finke, Williams, & Stanley,
1996; Lillibridge, Cox, & Cross, 2002), and addresses areas of attitude, risk factors,
treatment, recovery, and re-entry into practice, the lived experience of nurse colleagues
has been neglected. Many of the above studies explore chemically impaired nurses’
views of their colleagues from a qualitative perspective; however, the voice of the
colleague has been neglected. Thus, exploring nurses’ descriptions of their experiences of
working with chemically impaired colleagues benefits the field of psychology by adding
to the existing knowledge base in terms of understanding the needs of nurses who work
with impaired nurse colleagues. It provides new knowledge on chemically impaired
nurses from a perspective other than that of the impaired nurse. Finally, the qualitative
nature of this study and previous lack of scholarly exploration in the area of nurses
working with impaired colleagues propagates future research possibilities for
psychologists in other population work groups.








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Definition of Terms
The key phenomenon under investigation in this study was registered nurses’
perceptions of the chemically impaired nurse colleague as it was experienced by the
participants. To aide the reader, the following terms were defined as they were used in
this study and as reflected in the research questions:
Chemically impaired. The diminished ability to function in a professional role due
to the use of chemical substances (Miller-Keane, 2002) as reflected by the participants’
perceptions that their nurse colleagues’ work abilities had diminished because of a
chemical substance.
Colleague. A registered nurse who was the co-worker of another registered nurse.
Encountered. To have come upon unexpectedly (Webster’s New World College
Dictionary, 2003) as reflected by the participants who, by chance, personally experienced
working with an impaired nurse colleague.
Experiences. The state of being affected by an event (Webster’s New World
College Dictionary, 2003) as reflected by past activities or events that affected
participants’ perceptions and reactions toward chemically impaired colleagues.
Factor. The “circumstance, condition, detail or element which has a bearing on an
outcome” (Webster’s New World College Dictionary, 2003, p. 57) as reflected by those
circumstances, conditions, details, or elements of the situation, which the participants
perceived influenced their perceptions of working with chemically impaired nurse
colleagues.
Impaired nurse. A nurse who “habitually or excessively” uses or is dependent on
alcohol, narcotics, stimulants, or any other chemical agent or drug that results in inability







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to practice with reasonable judgment, skill or safety. Implies working under the influence
of non-prescribed mood-altering substances (Griffith, 1999, p. 24) as reflected by the
participants’ descriptions of an impaired colleague.
Influenced. Having had a “change in the character, thought, or action of” (New
World Dictionary, 2004, p. 628) as reflected by participants’ discussions of the factors
which caused a change in their perceptions of chemically impaired colleagues as they
answered the interview questions.
Interpersonal system. The interaction with the environment of a smaller group
within a larger group (King, 1981). King (1992) identified the concepts of
communication, interaction, stress, role, and transaction to be significant factors within
the interpersonal system. The interpersonal system was reflected by the factors related to
the concepts within the interpersonal system that participants’ identified as they answered
the interview questions.
Lived experience. The term used in phenomenological studies to emphasize the
importance of individual experiences of people as conscious human beings (Moustakas,
1994) as reflected by the actual experiences of the participants as they described it in
their own words.
Perception. The process of organizing, interpreting, and transforming information
from sense data and memory; the process of human transactions with the environment. It
gives “meaning to one’s experience, represents one’s image of reality, and influences
one’s behavior” (King, 1981, p. 24). Perception was reflected by the feelings, thoughts,
emotions, and ideas expressed by the participants as they answered the interview
questions.







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Personal system. King (1981) identified the concepts of perception, growth and
development, body image, self, learning, and time and space to be significant within the
personal system. The personal system was reflected by the factors related to the concepts
within the personal system that the participants identified as they answered interview
questions.
React. To act in response to as reflected by the participants to have responded to a
situation in which a colleague was working while chemically impaired.
Reaction. A “return or opposing action or influence” (Webster’s New World
College Dictionary, 2003, p. 118) as reflected by the response(s) influenced by factors in
the personal, interpersonal, and/or social systems of participants toward their chemically
impaired colleagues they worked with.
Registered nurse. A person licensed by the state board of nursing to practice
professional nursing in a given state (Delaune, 1998) as reflected by the health care
professionals, who met the criteria for selection for the sample of this study, and the
chemically impaired colleagues the participants described with whom they worked.
Social system. The circumstance, condition, detail or element which has a bearing
on an outcome as reflected by the factors related to the concepts of authority, control,
decision-making, organization, status, and power (King, 1981) that the participants
identified as they answered the interview guide questions.
Workplace. An area where one performs job tasks as reflected by that which was
described by each participant as being the place where he/she worked with a chemically
impaired nurse colleague.








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Assumptions
A key function in the analysis of the data was bracketing preconceived notions
and suppositions about the phenomenon. By acknowledging and suspending personal
biases, then putting them aside, the “life world” of the participants was revealed (Husserl,
1970). According to King (1981), nursing’s focus is on individuals interacting with their
environment, which leads to a state of health for individuals allowing them to function in
social roles. The following assumptions, several for which are consistent with King’s
(1996) theory, were made for this study:
1. Some nurses have health problems related to addictions and consequently may
practice while chemically impaired.
2. Being under the influence of alcohol and/or other mood altering substances will
influence nurses’ ability to practice safely and effectively.
3. Nurses, who are dependent on alcohol and/or other mood altering substances, can
regain their health by pursuing recovery from addiction.
4. The nurses’ “goals, values, and needs will influence” (King, 1981, p. 143) their
experiences and perceptions of chemical misuse and their reactions to colleagues
who practice while impaired.
5. The experiences of nurses and perceptions of nurses toward their colleagues who
practiced while chemically impaired will have influenced their interactions with
these individuals.
Furthermore, it was assumed that participants would be truthful in the descriptions
of their experiences and able to respond to all interview questions and to any additional







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demographic questions. It was also assumed that the participants would have a desire to
share their stories.

Limitations
Limitations are conditions beyond the control of the researcher that might restrict
conclusions of the study and how they might be applied to other situations (Best & Kahn,
1993). Possible limitations of this study and areas that were believed could not be
improved despite being a weakness included: (a) the findings of this study cannot be
generalized to all registered nurses who have worked with chemically impaired nurse
colleagues; (b) the findings of this study cannot be generalized to other populations of
individuals who have worked with chemically impaired colleagues; and (c) the findings
of this study were restricted to the recall ability of the participants of the study as there
was certainly the potential for underreporting of experiences by participants. According
to Van Manen (1990), we must “remain aware that lived experience is always more
complex than any explication of meaning can reveal” (p. 18). Thus, in relying on the
participants’ ability to recall and describe their experiences, I could never truly know that
the experience of working with impaired nurse colleagues from the perspective of
registered nurses was fully captured. The sample was also purposive and not
representative of the population of registered nurses who have experienced the same
phenomena. Experiences and perceptions of participants were their own and may not be
the same as other nurses. Finally, my interview experience was limited to a pilot study.









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