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
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Kimberly S. Esquibel, 2009
P R E V I E W 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 Kings (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 Colaizzis (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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iii 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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iv 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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v 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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vi Reporting Behaviors of Colleagues 41 Attitudes toward Impaired Nurse Colleagues 44 Legal and Ethical Considerations of Impaired Nurse Practice 47 Application of Kings 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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vii 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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viii List of Tables
Table 1: Correlation of Sub-themes Highlighting the Perceptions of the Participants with Kings (1996) Concepts within the Personal System 162
Table 2: Correlation of Sub-themes Highlighting the Perceptions of the Participants with Kings (1996) Concepts within the Interpersonal System 165
Table 3: Correlation of Sub-themes Highlighting the Perceptions of the Participants with Kings (1996) Concepts within the Social System 168
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1 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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2 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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3 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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4 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 colleagues 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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5 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 colleagues suspected problem violates a nurses 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 colleagues 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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6 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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7 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 colleagues 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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8 readings and study on the subject of chemically impaired nurses, Kings (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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9 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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10 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 (Websters 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 (Websters 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 (Websters 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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11 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 ones experience, represents ones image of reality, and influences ones 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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12 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 (Websters 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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13 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), nursings 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 Kings (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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14 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.