Recovery from Addictions in Healthcare workers - by Ann Sparks (research synthesis project 2011)

Running head: PERCEPTUAL CHANGES OF THE ADDICT IN RECOVERY 1
Perceptual changes of the addicted
health care practitioner in long-term recovery
Ann M. Sparks
Mennonite College of Nursing at Illinois State University

PERCEPTUAL CHANGES OF THE ADDICT IN RECOVERY 2
Abstract
Addictions are not uncommon within Health Care Practitioners (HCP) with full-blown dependency
sometimes exceeding a 15-20% prevalence rate (Luck & Hedrick, 2004; Monroe, Pearson & Kenaga,
2008). Since addiction has been defined as a disease, governing agencies have changed discipline
from being punitive in nature to a non-punitive approach. Within the National Council of State
Boards of Nursing (NCSBN), current research initiatives include “effective discipline and
alternatives to discipline” for nurses who suffer from addiction (2009-2012 Strategic initiatives and
research priorities, 2010). Medical policies for addictive behaviors are also aligned with this
philosophy (AMA, 2011; Merlo, 2009). Top goals of the NCSBN are seeking to protect patients and
to improve recovery levels of the addicted practitioner (Substance use disorder guidelines forum,
2010). That being said, perpetuating stigma and lack of information regarding mental health concerns
and addictions within practitioners remains problematic (Tognazzini, 2008). Therefore, this
qualitative study will examine the experiential journey and attitudes of 18 practitioners (nurses, mid-
level and physicians), from various regions of Illinois, who followed the non-punitive
recommendations and remained employed in their original health care career at least five years
beyond the initial confirmed addiction. This research proposal will include using a
Phenomenological Analysis of transcripts of interviews (Burns, 2009; Schultz, 2009) emerging
themes will be identified, and then compared to the theory of Modeling and Role Modeling. These
themes can then also be discussed in relation to previously existing policy, recovery literature, and
concepts of stigma, trust and social support.
~
Key Words: addiction, recovery capital, impaired, medical, nursing, practitioner, help-seeking,
stigma, social support, spirituality, perception.

Perceptual changes of the addicted
health care practitioner in long-term recovery
It is well known through the literature that health care practitioners (HCP), no matter whether
nurse, mid-level practitioner, or physician, are not immune to the disease of addiction. Wilson &
Compton (2009) report that 15% of nurses have used an illicit drug or abused alcohol in the past year
and 69% reported of lifetime history of (wrongful) use “on at least one occasion.” HCP have at least
the same prevalence of addictions and related co-morbid conditions as the general pubic, with the
rate of full-blown addictions possibly topping greater than 15-20% (Luck & Hedrick, 2004; Monroe,
Pearson & Kenaga, 2008). Merlo & Gold (2009) report that addiction causes more physician
impairment than any other disease. Chemical dependency crosses all socioeconomic lines and
according to Narcotics Anonymous (2008), as the addict believes, “drugs had given us the feeling
that we could handle whatever situation might develop,” with denial being a common denominator.
Because of the nature of addiction and associated mental illnesses (of depression and suicide), the
two concepts cannot be fully separated according to the U. S. Dept of Health and Human Services
speaking of comorbidity (2010), and often times addiction left untreated will end up in death (Clark
& Farnsworth, 2006; Hegner, 2000; Luck & Hedrick, 2004; Miller, 2000; Merlo, 2009; Narcotics
Anonymous, 2008).
The problem: unfortunately, even though addiction prevalence is known to be nearly one in
five within our own profession, we as practitioners actually know very little about the disease, or
recovery, and we often actually perpetuate stigma (Tognazzini, 2008), even towards our own
colleagues. Basic questions that present themselves are, “What have addicted practitioners
experienced?” and “What perceptions do recovering health care practitioner addicts have, that
contribute to their success?” This qualitative study using a descriptive phenomenological approach is
designed to increase practitioner awareness of the disease of addiction within healthcare
practitioners, and to address the issue of stigma head-on by getting to know the perceptions of a few

recovering practitioners who are likely working with us, “side-by-side,” in the clinical environment.
By pulling together the views of nurses, mid-level practitioners and physicians, social strata
differences will be intentionally ignored in this study, since we all share likenesses common to
humanity (Schultz, 2009). We will look at the views of addicted practitioners who have successfully
moved through a non-punitive program of recovery. The focus will be on those who have achieved
long-term recovery (abstinence) and their perceptions of stigma, social support, and spirituality in the
past and present.
The results will be compared to the Modeling and Role Modeling (MRM) theory, the
paradigm of recovery espoused by previous researchers, and the themes can then also be discussed in
relation to previously existing policy, literature, and concepts of stigma, trust and social support.
Review of the Literature
Chemical dependency is a very complex disease that is life-long and cannot be “cured”
(Narcotics Anonymous, 2008), therefore a consistent program of recovery is required to maintain
abstinence. Tackling the problem requires a multidisciplinary approach to this multifaceted problem.
There is a fair amount of research available on practitioner addiction identification, non-punitive
treatment modalities, spirituality and social supports. But little literature can be found looking at the
perceptions of the addict working in the healthcare field who is working a successful program of
long-term recovery and health care practitioner stigma towards addictions. Quinlan (2009) tracks the
25-year history of a peer assistance program for nurse anesthetists who struggle with addictions.
The theoretical literature sources from which the concept analyses of stigma, social support
and spirituality are quite varied, and also include the background of the problem of addiction and
complicating co-morbidities within healthcare practitioners (Adams, Lee, Prichard & White, 2010;
Cashwell, Clark & Graves, 2009; Corrigan, 2008; Galanter, 2006; Hegner, 2000; Link & Phelan,
2001; Merlo & Gold, 2009; Miller, Mcgowen & Quillen, 2000; Narcotics Anonymous, 2008;
NCSBN, 2010; Tognazzini, Davis, Kean, Osborne & Wong, 2008; U.S. Department of Health and

Human Services, 1999 & 2010). Even though we have looked at the conceptual definitions, the
participants of the study will carry out their own extensive definitions based on their experiences in
successful long-term recovery. The theoretical framework of Modeling and Role Modeling (Shultz,
2009) takes a superior “holistic, patient-focused” approach that includes a spiritual component and a
non-judgmental approach by the practitioner, “supporting the client‟s model of the world.” This
philosophy will guide this study to the end, when the study results will be compared to the theory.
Empirical literature supports examining spirituality (Carter, 1998; Shealy, 2010; Shockey,
Uegel & Windsor, 2008) and demonstrates the need for spiritually based recovery, thus further
examination will be obtained through this study. Comparison of non-punitive recovery programs
demonstrate that there are various approaches that may be taken to provide direction for treatment
early in recovery (Clark & Farnsworth, 2006; Monroe, Pearson & Kenaga, 2008; Monroe, 2009) and
addictions science has not yet settled on one definitive approach. Recovery capital of social
supports, spirituality and 12-step affiliation (Laudet & White, 2008) are discussed in detail, giving
groundwork for future comparisons of study information. Consequences of stigma (Link, Struening,
Rehave, Phelan & Nuttbrock, 1997) on recovery efforts give an historical context of stigma research.
A descriptive analysis of prevalence of the disease of addiction in nursing students (Monroe, 2009),
and anesthesia providers (Luck & Hedrick, 2004) providing more evidence that all practitioners need
to be included in this study.
Of the 32 listed references, 28 sources (87%) were published within the past 10 years. The
remaining five references include two U.S. Surgeon General reports that are 11 and 12 years old
respectively (no more-recent reports were available on the web sites), and three articles were 11, 13
and 14 years old, have been used as supportive literature for the background of the problem and some
of the roots of spiritual underpinnings of the disease and recovery. Considering the prevalence of
addiction, it is clear that the literature is pertinent and applies to every practice setting as we view
ourselves, and our colleagues, and as we care for our patients. With the high accessibility of mood

altering medications within our daily work, and stressful working conditions, education for nurses
and physicians, as well as further research, are indicated regarding mental illness/addictions, stigma
and self-help behaviors related to these diseases and concepts.
Modeling and Role Modeling as the Theoretical/Conceptual Framework
Addictions recovery is a holistic growth process of recovery capital including social supports
and spirituality (Laudet & White, 2008; Galanter, 2006; Narcotics Anonymous, 2008). These
concepts blend beautifully with the integrative middle-range nursing theory of Modeling and Role
Modeling (MRM) since it is client-centered, placing the client‟s perceptions at the center of the
interaction throughout the healing process (Schultz, 2009). This holistic theory integrates multiple
disciplines of psychosocial development of Erickson, cognitive development of Piaget, basic human
needs of Maslow, and stress adaptation of Selye and Engle, encouraging the nurse to “nurture the
client (and) facilitate, not effect, the adaptive process, and accept the „client unconditionally.‟”
According to Tognazzini (2008; Adams, et al., 2010), health-care providers actually perpetuate the
stigma associated with mental illness. By reviewing these issues from a qualitative perspective, we
can easily see that we cannot sit in judgment of those who suffer from the disease of addiction,
whether they are our patients or our colleagues (who may need to be patients too), making this topic
highly applicable in all levels of health care.
Concepts from the MRM theory have guided the development of this study; according to
Schultz (2009), the MRM framework identifies that persons are unique, and yet clearly identifies that
all persons are alike in that the systems of mind, body and spirit do not work independently of each
other. They are integrated and work dynamically with the biophysical, psychosocial, cognitive and
social aspects of the person to function as a whole. Social supports are critical in the human
construct, just as “spiritual energy unifies the dimensions of the holistic person.” The works of Carter
(1998), Cashwell, et al. (2009), Shealy (2010), and Shorkey, et al. (2008) are also in agreement,
pointing towards the direct link of spiritual growth as a foundation for addictions recovery. The

foundational statement of Narcotics Anonymous (2008) is “this is a spiritual program” for a disease
that affects the mind, body and spirit.
With stigma and fears being a few of the primary reasons addicts avoid treatment in the first
place (Adams, et al., 2010; Clark & Farnsworth, 2006; Corrigan & Wassel, 2008; Hegner, 2000;
Link, et al., 1997; Merlo & Gold, 2009; Tognazzini, 2008), we will look at the conceptual definitions
of stigma, social support (Quinlan, 2009) and spirituality. It is out of these concepts that the
phenomenological study questions will be formulated for the participants.
Conceptual definitions of this study
Stigma
According to Link and Phalen (2001) stigma “exists when elements of labeling, stereotyping,
separation, status loss, and discrimination occur together in a power situation that allows them.” The
two aspects of stigma are 1) looking at the one who is doing the discriminating, and 2) looking at the
recipients of the discriminating behavior. The implications are far-reaching, even to the point of
being a persistent dilemma. The research of Link, et al. (1997) discovered that even a full year after
significant improvement of mental health and comorbid addiction symptoms, stigma was found to
still have a profound affect on the well-being of the clients. Stigma must be eradicated from our
perceptions (U. S. Department of Health and Human Services, 1999) and we practitioners need to
evaluate our own beliefs, to become knowledgeable about how we affect health care culture, and to
demonstrate a climate of social justice, respect, dignity and integrity (Tognazzini, 2008).
Social Support
The conceptual definition of social support has long been known as the perception of feeling
loved, cared for, esteemed and valued by people in close association with the participant. By seeking
out social support, the individual is resisting isolation, which is a symptom of the disease of addiction
(Laudet & White, 2008; Narcotics Anonymous, 2008).
Spirituality

The construct of spirituality has long been linked within the foundation of healthy recovery
from addictions. Many of those in recovery have identified spiritual aspects of their lives as being
central to recovery (Carter, 2001; Cashwell, et al., 2009; Galanter, 2005). Within a healthy
spirituality, the participant believes that a Higher Power (Laudet & White, 2008; Narcotics
Anonymous, 2008) plays a significant role in life, and that personal strength and support can be
ascertained from that Power. Spiritual principles such as humility, love, serenity and gratitude are
gained through that relationship, and that some consider maturity in that process to be “spiritual
enlightenment,” another aspect of recovery capital.
Study Design and Methods
Design
The background of this study is focused on the concepts of stigma, social support and
spirituality, and the problem of practitioner lack of knowledge of the disease of addiction and
associated stigma, particularly within the health care profession.
By performing this qualitative phenomenological study the researcher “dwells with” the experience
of the participant (Burns, 2009) and therefore the impact if stigma, social support and spirituality can
be better understood. By studying successful practitioners in recovery five years after originally
entering non-punitive programs of recovery, the full impact of recovery “ownership” and conceptual
definitions will be recognized.
The Research Questionnaire.
In looking at the research questions of “What have addicted practitioners experienced” and
“What perceptions do recovering health care practitioner addicts have, that contribute to their
success?” we will use the following basic questionnaire. This study will focus on several open-ended
questions that the participant will be encouraged to expound upon through an audio-visual taped
interview. The introductory question, plus three questions about experiences in the recovery process
will be asked of the health care practitioners:

1. What is your title and role as a Health Care Practitioner?
2. What were your challenges of addiction in the beginning?
3. What has your own program of recovery been like?
4. How have you changed (your perceptions) through the program of recovery?
Appendix A shows extensions of these questions and prompts for the participant to add
further discussion into areas of perceptions related to early recovery, current recovery program, and
perceptual changes that have occurred over time. The researcher would take notes during the
interview process and could repeat the questions being asked. The key would be to increase an
environment of trust and respect between researcher and informant (Speziale, 2007). As the
interview proceeded into the unstructured portions, the researchers might continue with questions
such as “What was that experience like for you?” in regards to feeling stigmatized, being held
accountable at different levels of recovery, and the like.
Method
By using the Parse methodology of a phenomenological study, data collection would be by
personal interview using a videotape to multi-sensorily immerse the researcher into the data (Burns,
2009). The open-ended interview questions will serve to open up to unstructured conversation with
the purpose of answering the research questions (Speziale, 2007), but allowing the conversation to
flow in an open-ended fashion.
Target population.
The target population of interest will be the health care practitioners who are addicted (to any
mood altering substance) in Illinois, successfully working a non-punitive program of recovery for at
least five years (from the time of first diagnosis of addiction), and clean/sober time of greater than
three years.
Study Sample.

Appendix B shows an Illinois regional map of six areas (Illinois Department of Public
Health, 2011) from which one nurse, one mid-level practitioner, and one physician would participate
in the study for a total of 18 participants. The best sampling method for this study would be
snowballing (Speziale, 2007; Groenewald, 2004). That is, “using one informant to find another” to
locate difficult to find participants. If it became evident that saturation of data was not being met
during the research process, a second participant from each of these categories would be secured
through which further study information would be sought. Speziale reports that to assure thorough
data extraction, samples from a variety of backgrounds, ages, and cultural environments need to be
obtained.
The criteria for this study includes that the participant be involved in a non-punitive program
of recovery for at least 5 years, and that there has been no relapse within the past 3 years. The
participant must also state that he/she is an addict or alcoholic and the participant must have
remained employed in original licensed role during recovery. All questions and sub-questions of the
questionnaire must be answered with reasonable completeness to provide meaningful data for the
study.
Instruments and trustworthiness.
As previously noted, the researchers interviewing the practitioners could repeat the questions
to the respondents. Also, further unstructured open-ended questions would be encouraged, such as
asking what certain experiences were like in regards to stigma, spirituality, social support and
accountability. To assure trustworthiness, a researcher would be involved in the study that has
extensive qualitative research experience to assure accuracy and so as to reduce the chance for error
in transcribing and categorizing the data into themes. In addition to this, a return interview would be
scheduled to ask if the exhaustive description given by the participant (now transcribed in writing
and categorized into themes) clearly reflects the participant‟s experiences. An audit trail would be
left for further examination to be available for future reference for confirmability. Before beginning

the interview process, all experiences and biases of the researchers would be documented and
reviewed (Speziale, 2007; Burns, 2009), and any significantly biased attitudes perceived regarding
addiction or addiction recovery would disqualify the researcher from the study. Unconditional
acceptance of the informants and the discussions would be essential for trust to be maintained, as in
accordance with the MRM nursing theory.
Explicitation of the data.
A research mentor (Speziale, 2007) would be engaged in the process of data division into
themes and analysis and interpretation of the data obtained. “The explicitation process has five
„steps‟ or phases, which are: 1) Bracketing and phenomenological reduction. 2) Delineating units of
meaning. 3) Clustering of units of meaning to form themes. 4) Summarising each interview,
validating it and where necessary modifying it, and 5) Extracting general and unique themes from all
the interviews and making a composite summary (Groenewald, 2004).” Initial themes of recovery
capital would be easily identified, such as social supports, spirituality, and perceptions of stigma and
discrimination. But as the interviews opened up into an unstructured format, the further need for
specialists in the social and addictions sciences may be necessary to interpret the data appropriately.
Findings from the study would have multiple applications including comparison with
previously existing policy, recovery literature, and concepts of stigma, trust and social support.
Protection of participants
For appropriate ethical clearance, Illinois State University‟s IRB would be consulted with full
study details, and full written consent of the participants, assuring strictest confidentiality, would be
obtained.
Dissemination of the Project
This proposed research is applicable to all levels and specialties of health care practice. All
practitioners would benefit from the knowledge of such a study to open up discussion, self-
examination, as well as to encourage reporting on a “caring level, rather than punitive, judgmental

level.” This information would not necessarily be intended for public knowledge as it may
negatively affect public opinion of health care practitioners. Consulting a marketing strategist may be
beneficial, and it might be best to create a glossy color flyer that has the heading labeled, “A deeper
level of caring – collegial support through difficult times.” This title would tap into the practitioner‟s
sense of caring and may trigger a memory of a situation where a colleague might have been able to
benefit from early intervention as a result of being “impaired.” The flyer would be sent by mail to all
Illinois medical and nursing practitioners (including RNs and LPNs). It would even be beneficial to
offer regional conferences on such a topic of “Caring: stigma, addictions and collegial
responsibility” with the offer of CEUs for all professionals attending. Illinois could well serve as a
pilot study for National application of the information in the future.
Summary and Conclusion
Addiction is clearly disease that touches our lives profoundly, both within our patients and
within our professions. As many as one in five practitioners suffer from mood altering chemical
misuse and/or addiction (Luck & Hedrick, 2004; Monroe, Pearson & Kenaga, 2008). Our caring
professions of nursing and medicine are over-ridden with high stress, long hours, access to drugs,
expectations (real or perceived) of perfectionism, and stigma that keeps us from seeking the help we
need. Shall we allow these stigmas and fears to keep us from discussing the topic on a truly caring
level of compassion and respect? The research will help us “get to know” addicted colleagues, so that
we may become more understanding and empathetic. This disease is like any other disease that we‟d
seek help for, or encourage others to do so. Let us become educated and not contribute to the
perpetuation of stigma and disease. Through the theory of Modeling and Role Modeling, we can
practice integrity and pave the way towards stamping out prejudice and stigma. Let us meet patients
where they are at, encourage hope, and practice caring as we encourage effective treatment towards
addiction recovery. The next colleague needing help might just be your best friend or your self.

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APPENDIX A
The Interview Questions
1) What is your title and role as a Health Care Practitioner?
2) What were your own challenges of the addiction in the beginning?
Stigmas – guilt & shame?
Fears of
License suspension/revocation?
What others think?
Issues of denial
Problems with isolation
Who could comprehend what I was going through?
Was I lonely, even when not alone?
Couldn‟t share weaknesses or feelings of inadequacy with others?
A sense of “spiritual bankruptcy”
Did I have self-centeredness and lack of spiritual principles?
3) What has your program of recovery been like?
The process of recovery
How I got into Treatment & aftercare – What choice was I given?
12-Steps? Alternative program of recovery? Special Caduceus group?
NA/AA/other support groups? What I do now for my recovery?
Feelings of stigma now, and what I‟d like my peers to know.

APPENDIX A
The Interview Questions (continued)
4) How have you changed (your perceptions) through your program of recovery?
Have I learned to view things differently?
Stigmas & Fears – have my perceptions changed?
Social support versus isolation
 How have my support systems changed?
Trust, transparency and accountability with (talk in detail about each below)
With Self
With Peers in the program
With Sponsor (N/A?)
With Accountability partner(s) (N/A?)
With Family
With Employer
With licensing agencies.
 Did you utilize a12-step Program? Talk in detail about your recovery – program, fellowship(s)
and/or support group(s).
Spiritual principles & my concept of a Higher Power
Are you still being monitored through random drops?
How do I feel about that?
Do I need an external motivating source to keep me accountable?
Talk about your level of “ownership” of your recovery program.

APPENDIX B
Regional Illinois Map (IDPH, 2011) demonstrating regions of sampling for study
RN/LPN Mid-Level Physician
Region 1
Region 2
Region 3
Region 4

Region 5
Region 6

Recovery from Addictions in Healthcare workers - by Ann Sparks (research synthesis project 2011)

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