810655

research-article2018

GQNXXX10.1177/2333393618810655Global Qualitative Nursing ResearchRoss et al.

Single-Method Research Article

“A Two Glass of Wine Shift”: Dominant
Discourses and the Social Organization
of Nurses’ Substance Use

Global Qualitative Nursing Research
Volume 5: 1­–12
© The Author(s) 2018
Article reuse guidelines:
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https://doi.org/10.1177/2333393618810655
DOI: 10.1177/2333393618810655
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Charlotte A. Ross1,2 , Sonya L. Jakubec3, Nicole S. Berry1,
and Victoria Smye4

Abstract
We undertook an institutional ethnography utilizing the expert knowledge of nurses who have experienced substance-use
problems to discover: (a) What are the discourses embedded in the talk among nurses in their everyday work worlds that
socially organize their substance-use practices and (b) how do those discourses manage these activities? Data collection
included interviews, researcher reflexivity, and texts that were critically analyzed with a focus on institutional features.
Analysis revealed dominant moralistic and individuated discourses in nurses’ workplace talk that socially organized their
substance-use practices, subordinated and silenced experiences of work stress, and erased employers’ roles in managing
working conditions. Conclusions included that nurses used substances in ways that enabled them to remain silent and keep
working. Nurses’ education did not prepare them regarding nurses’ substance-use problems or managing emotional labor.
Nurses viewed alcohol as an acceptable and encouraged coping strategy for nurses to manage emotional distress.
Keywords
nurses, addiction / substance use, health care, work environment, health care professionals, qualitative research, nurses’
work life
Received June 12, 2018; revised October 8, 2018; accepted October 9, 2018

Introduction
Nurses’ problems with substance1 use can pose serious risks
to their health and well-being (Kunyk, Inness, Reisdorfer,
Morris, & Chambers, 2016) and potentially compromise the
provision of safe, competent nursing care to the public
(Kunyk & Austin, 2011). Estimates of the prevalence of
nurses’ problems with substance use in Canada and the United
States range from 6% to 20% (Dunn, 2005; Kunyk, 2015;
Monroe & Pearson, 2009; Servodidio, 2011). New enrollees
in substance-use monitoring programs for nurses in the
United States and its territories in 2009 comprised 0.36% of
the national nursing population (Monroe, Kenaga, Dietrich,
Carter, & Cowan, 2013). We found it particularly concerning
that many nurses with such problems are reluctant to obtain
help and remain in practice (Bell, McDonough, Ellison, &
Fitzhugh, 1999; Kunyk, 2015; Monroe et al., 2013). In one
study in the Canadian province of Alberta, more than 90% of
the nurses who self-identified as having problems with substance use were actively practicing and had not sought treatment (Kunyk, 2015).
Our concern with this serious issue arose from firsthand
knowledge of both the everyday work lives and substance-use

practices of nurses. Many of our nursing colleagues have
lived with substance-use problems, either in secret or, if discovered, in disgrace. Tragically, some did not survive. This
perspective was our entrée into a study of what, within the
complex work worlds of nurses, might socially organize the
conditions for them to have such problems and to be reluctant to seek help when they do.
Our next step was to review scholarly literature (Ross,
Berry, Smye, & Goldner, 2018). Dominant concepts used
to explain nurses’ perspectives of substance-use problems,
such as stigma (Darbro, 2005), negative attitudes (Howard
& Chung, 2000), and the culture of the nursing profession
(Darbro & Malliarakis, 2013; Solari-Twadell, 1988) permeated much of the existing research. Numerous
1

Simon Fraser University, Burnaby, British Columbia, Canada
Douglas College, Coquitlam, British Columbia, Canada
3
Mount Royal University, Calgary, Alberta, Canada
4
Western University, London, Ontario, Canada
2

Corresponding Author:
Charlotte A. Ross, Douglas College, Office #C3054, David Lam Campus,
1250 Pinetree Way, Coquitlam, British Columbia, Canada V3B 7X3.
Email: car12@sfu.ca

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons AttributionNonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction
and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages
(https://us.sagepub.com/en-us/nam/open-access-at-sage).

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conceptualizations of substance-use problems were also
offered, such as problematic substance use (College of
Registered Nurses of Nova Scotia, 2017), substance-use
disorders (Monroe, Vandoren, & Smith, 2011), addiction,
and substance abuse2 (Monroe & Kenaga, 2010). Popular
themes of contributory factors also pervaded: stress (Storr,
Trinkoff, & Anthony, 1999; Trinkoff & Storr, 1998),
nurses’ access to drugs (Dittman, 2008; Kenna & Wood,
2004b), and nurses’ attitudes toward substance use (Kenna
& Lewis, 2008; Lillibridge, Cox, & Cross, 2002). However,
a critical interrogation of how these very concepts and
themes originated and were constructed was notably
absent. We found ourselves puzzled about how these
abstract concepts and themes connected to what we knew
about nurses’ actual work lives and substance-use practices, and believed that there was much more depth and
texture to the story than was being told. Moreover, the
nursing literature on the topic was dominated by quantitative research, with precious few qualitative studies that
used the experiential knowledge of nurses who had substance-use problems as primary data.
We also felt a disjuncture3 arising from what we saw as
the decontextualization of the issue in the extant scholarly
works. Nurses’ problems with substance use have been principally framed in neoliberal terms of individual shortcomings (Kunyk, Milner, & Overend, 2016), whereas broader
institutional and organizational conditions have neither been
critiqued nor researched (Ross et al., 2018). This trend conflicted with what we knew experientially about the interconnections between nurses’ substance-use practices and their
workplaces. That individuated perspective also contradicted
current public health–based approaches that consider the
environment as the primary focus of inquiry into substanceuse problems (Rhodes, 2002).
The disjunctures that we experienced, whereby our own
experiential knowledge of nurses’ problems with substance
use and the conditions of their day-to-day work lives met with
conflicting organizing discourses, became the problematic of
our study. A problematic is a “puzzle” in the social world, in
which disjunctures are explored with the aim of discovering
how the lives of individuals involved are socially organized to
occur as they do (D. E. Smith, 2005). We chose to address the
shortcomings that we found in the existing literature and
examine the disjunctures that we were feeling by using an
institutional ethnography (IE) mode of inquiry to explore our
problematic.
Numerous avenues of inquiry exist within a problematic,
all arising from differing standpoints, or the particular
knowledge and social locations of individuals situated in the
problematic (D. E. Smith, 2005). We elected to align with a
standpoint different from our own as the entry into the problematic and utilized the expert experiential knowledge of
nurses who have experienced substance-use problems to
research two questions:

Global Qualitative Nursing Research
Research Question 1: What are the discourses embedded
in the talk among nurses in their everyday work worlds
that socially organize their substance-use practices?
Research Question 2: How do those discourses manage
these activities?

Research Approach
Institutional Ethnography
In the IE tradition, the process of inquiry is anchored in the
everyday experiences and practices of people, rather than in
abstracted notions such as concepts and themes. The IE
researcher’s main objective is to trace that local experience
outward to discover how those experiences are managed,
socially organized, and ultimately subordinated by broader
ideological constructions of reality that are embedded within
dominant discourses (Campbell & Gregor, 2002; D. E.
Smith, 2005). In IE, discourses are seen as the words (in talk
or texts) people take up in their day-to-day worlds that serve
as maps, guiding them to the knowledge of “what they should
be doing” (Clune, 2011, p. 41).4 As with Foucault’s discourse
analysis, Smith’s IE approach aims to expose social and
power relationships within textual discourses; however,
Smith’s IE approach examines how these discourses are
joined with social practices, particularly in institutions or
work environments (Campbell & Gregor, 2002).
Language is the door through which a researcher can enter
into and uncover the discursive organization that is hidden
within everyday activities. The ways nurses talk, like all professional conversation, is laden with institutionalized parlance.
D. E. Smith (1999) observed that an “intimate connection
[exists] between learning an occupation and learning a language” (p. 144), in that, typical insiders’ talk organizes the
occupational group members’ knowledge as it becomes
adopted as taken-for-granted group norms. The talk is practiced, as these norms act as dominant discourses that inform
and organize the group members’ day-to-day activities. As the
discourse is reproduced in nurses’ talk, it acts as a generalizing5 process that, in turn, coordinates and manages nurses’
activities across other settings and times (D. E. Smith, 2005).
We uncovered how dominant discourses were reproduced
within and across nursing work sites by ethnographically
researching the ways the nurse participants talked in interviews about their substance use and everyday work lives,
and their recounting of how other nurses talked about these
matters. The historical importance of professional nursing’s
oral traditions has been recognized in foundational nursing
work (Benner, Tanner, & Chesla, 2009). However, during
our comprehensive literature review on nurses’ substance
problems (Ross et al., 2018), we found that the ways that
nurses talk about their substance-use practices had remained
unexplored. We believed that we could utilize this untapped
resource to gain access into nurses’ everyday work worlds

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Ross et al.
through the actual words spoken by nurses, the subtexts, the
words they did not speak, the stories they told, how they
talked as and among nurses about substance use, and how
this talk was enacted in their everyday work lives.

Method
Participants
Inclusion criteria for the standpoint participants (referred to as
participants in what follows) in our study required that they
were registered nurses (RNs) or registered psychiatric nurses
(RPNs), they were a current or past enrollee in the regulatory
program in one Canadian province for nurses who were
declared to have substance-use problems, and they worked in
provision of direct patient care. We carried out recruitment via
an advertisement posted in one of the provincial nursing organizations’ e-newsletters. Participants included 11 RNs and one
RPN. Nine of the participants had responded to the recruitment
advertisement and three other nurses contacted us because they
had heard about the study from nurse colleagues.
In IE, the number of participants is not prescribed; instead,
importance is placed on participants representing a sufficiently diverse range of experiences and loci within the institution to illuminate the generalization of discourses across
different times and places (DeVault & McCoy, 2006;
Malachowski, Boydell, Sawchuk, & Kirsh, 2016). Our participants were employed in various types of clinical areas
and in different units, hospitals, and regional health authorities throughout the province. Participants varied in age and
length of time in nursing, had problems with different substances, and were of male and female gender identifications.
Due to the extremely sensitive nature of the topic, we have
not identified the specifics of any of these demographics in
this article to protect participants’ anonymity and confidentiality. We obtained all relevant research ethics board approvals and institutional consents prior to conducting the research.
Participants provided informed, written consent to participate in the study. We strictly protected participants’ confidentiality and anonymity, and all participants’ names reported
in this article are pseudonyms.

Data Collection
The written and spoken language practices of nurses obtained
in participant interviews and Ross’s (i.e., the lead author’s)
journal (described below) served as ethnographic data for the
analysis. The lead author conducted all the interviews with
participants, which took place either in person or via Skype
(Microsoft, n.d.) in 2016 and 2017 as semistructured, audiotaped one-to-one interviews of 60 to 90 minutes in length.
Most were single interviews, but the lead author contacted
some participants for a second brief interview or collected
subsequent information via an email if we required clarification or additional data. We provided participants with copies

of their written interview transcripts and gave them an opportunity to provide comments, clarifications, or corrections as
they saw fit.
Reflexivity involves making the research process itself a
focus of inquiry (Carolan, 2003). As researchers’ reflexivity
is considered “a valid means of adding credibility to qualitative research” (Carolan, 2003, p. 10), we used the lead
author’s reflexive knowledge, in the form of a written journal
(with entries prompted by interview experiences), as data in
this study. We have included excerpts from the lead researcher’s reflexive journal in our analysis, which are cited with the
code LRJ in the findings. The lead author occupied a dual
standpoint with respect to the participants. The lead author
was also a practicing nurse (dually credentialed RN and
RPN) with more than 36 years of experience. This provided
the lead author with an insider’s understanding of nurses’
typical language and expressions, their conditions of work,
the corporate and operational workings of health care institutions, and systems of nursing education. Unlike the participants, the lead author had not had any involvement with any
nursing regulatory body because of substance-use problems.

Data Analysis
Traditionally, IE researchers analyze the language within
institutional texts as data (Campbell, 1994; Diamond, 1992;
Rankin & Campbell, 2006). Recently, D. E. Smith (2017)
endorsed the notion of researchers undertaking “an ethnography of words as uttered” (p. 24) in her important work, Talk
as Practice. As with the IE research of Watt (2017) concerning emotional work in the care of children with diabetes and
G. W. Smith and Smith’s (1998) study of school experiences
of gay students, we have taken the approach of foregrounding talk in our analysis of social practices and relations.
Rigor in IE is achieved by “the corrigibility of the developing map of social relations” (DeVault & McCoy, 2006, p.
33), and is accomplished through a confirmable and accurate
accounting of the actualities of peoples’ lives, discovering
how individuals’ knowledges have been organized, how
knowledge manages people’s everyday activities, and how
these knowledges and actions are coordinated with those of
others. To achieve our research aims, we used indexing and
mapping, analytic strategies typically employed in IE
research (Rankin, 2017). The lead author carried out a preliminary review of the data from participants’ interviews and
the reflexive journal, using manual notations on the transcripts to index (a) how nurses talked (and did not talk) about
substance use and (b) the participants’ day-to-day work. In
IE, work is broadly conceptualized as “what people do that
requires some effort, that they mean to do, and that involves
some acquired competence” (D. E. Smith, 1987, p. 165).
This “generous” notion of work (D. E. Smith, 2005, p. 151)
incorporates less visible types of labor, such as cognitive,
emotional, and communication work, as well as visible physical activities. Locating work in ethnographic data is

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fundamental to an IE analysis (D. E.Smith, 2005), as it
guides the analyst’s attention to the activities of the participants and the knowledge that informs these actions.
In the second and subsequent readings, these two indices
were further subindexed with the goals of (a) uncovering and
describing dominant discourses in the nurses’ work lives and
(b) mapping how these discourses entered into the nurses’
day-to-day experiences (McCoy, 2006). In IE, mapping
describes and traces people’s activities (including talk) by
“lay[ing] out a display of what is happening (the map), either
in words or diagrams, that describes the features of the social
practices” (Rankin, 2017, p. 5). In carrying out this analysis,
we were watchful for tacit, taken-for-granted assumptions,
and recurring events or use of words. These could uncover
patterns that existed in local actors’ (in this case, nurses’)
day-to-day work worlds that were socially organized to be
repeated or generalized in other locations and times
(Campbell & Gregor, 2002; D. E. Smith, 2005). We were
also alert for disjunctures that occurred between nurse participants’ experiential knowledge and ideological or conceptual ways of knowing imposed by dominant discourses. This
directed our attention to where the participants’ knowledge
and experiences were subordinated to those discourses (D. E.
Smith, 2005).

Findings
Our analysis of interview transcripts and the lead researcher’s journal (LRJ) uncovered that our participant nurses’ substance use and coping practices were socially organized by
dominant discourses embedded in the ways nurses talked (or
did not talk) in their everyday work lives. These included
othering practices, meaning, practices of distancing through
stereotyping into us and them categories (nonnurses and
nurses with substance-use problems as others, and substanceuse problems as other health issues); professional education
practices; coping practices (coping with silence and using
substances); and the work of managing disclosure (the paradox of obtaining help for and the work of concealing substance-use problems).

Othering Practices
Our data revealed underlying discursive categorizations in
nurses’ talk, whereby people with substance-use problems
were viewed as others who were separate from nurses; nurses
who had substance-use problems were seen as different from
and lesser than nurses who do not; and nurses with substanceuse problems were viewed as different from and less worthy
of empathy and support than those with other types of health
issues.
Othering practices toward nonnurses with substance-use problems.
Participants reported that nurses typically spoke of their
patients and those in the broader community who had

Global Qualitative Nursing Research
problems with substance use in ways that were contemptuous
and markedly lacking in empathy. As Paul articulated, people
with substance-use problems were “just looked down upon
[by nurses], not ever with any sympathy, but more of a weakness . . . that they’re a lesser person because they’re having to
use.” Participants told us that, in their day-to-day work, nurses
typically spoke about people with substance-use problems in
terms of moral or character deficiencies, social deviance, or
low standing and used phrases such as “bad,” “weak,” “lowclass,” “skanky,” “uneducated,” “from skid row,” “addicts,”
and “junkies.” Participants identified that prior to and even
during their active substance-use problems, they had themselves thought and spoken in this typical judgmental way
about people with such problems. In contrast, nurses characteristically spoke of themselves as being “educated,” “respectable,” separate from, and elevated above these distinctly
undesirable other people. Rachel recounted, “I believed, you
know, I’m not like those other addicts. I’m not a junkie that
shoots heroin on the street . . . I’m not the same as them.”
Othering practices toward nurses with substance-use problems.
This discourse coordinated nurses’ activities by stipulating that
they must be seen to be able to “handle” their substance use to
retain their elevated moral, characterological, and social status.
The participants recounted that they and their colleagues
expected nurses to know better and definitely do better than to
have such problems. Nurses who were discovered to have problems with substance use were othered as nurses, and viewed as
incompetent, weak, immoral, and poor representations of the
nursing profession. Participants reported that they had adopted
and internalized this discourse as part of their nursing identity,
and, subsequently, they experienced profound feelings of shame
and embarrassment, and felt that they had failed as a nurse when
they realized that they had a substance-use problem.
Othering practices toward substance-use problems. Participants
recalled that nurses rarely spoke of people’s problems with
substance use as illnesses or health issues, although there
seemed to be an expectation that they really should view
them as such. When substance-use problems had been spoken of as health issues, it was clear to the nurses so affected,
they were essentially considered as illegitimate illnesses.
Helen and Paul illuminated how compassion was selectively
practiced toward colleagues according to the type of health
issue that they were dealing with. When asked whether she
would have felt more supported by colleagues if she had
said, for instance, that she was off work with a back injury
instead of for treatment of substance-use problems, Helen
explained, “I think I actually said that one of the times
[laughs] actually I said that almost every single time.”
Participants told us how nurses typically felt isolated and
unsupported when they were “outed” as having a substanceuse problem. Paul described how compassion from colleagues fell short during leave related to his problems with
substance use:

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Ross et al.
Not one person sent me a get-well card. We’re always putting
money in for people who are off sick to buy them flowers or
something, but I didn’t get anything [when off work for treatment
of substance-use problems] . . . It’s all “it’s an illness . . . except
for how we’re going to treat you.”

As Paul recounted about his workplace, if a fellow nurse
was known to have a physical health issue, support was
extended both formally and informally. Many participants
reported that, like Paul, if the nurse’s health was affected by
substance use, then he or she would most likely experience
blame, condemnation, and/or exclusion.
According to our participants, their colleagues did not
understand relapse as an expected part of the course of recovery from substance-use problems. Instead of a symptom of a
health issue, relapse was spoken about as a characterological
failure and even a betrayal of the profession. As Mark
described, “When I went back to work after I’d relapsed . . .
the head nurse told me that—to my face— ‘you’re not trusted
here because you lied and you disappointed and betrayed
your colleagues.’” Even nurses who had not relapsed worked
in an atmosphere of deep mistrust, where it was assumed that
they had or inevitably would do so. Pietra explained the attitude of suspicion present in the work setting in this way:
They wonder if you are going to relapse . . . There’s a suspicion
. . . and you can feel it because you’re judged . . . I’m absolutely
terrified there’s going to be a discrepancy in the narcotic count
. . . I’ve been called in three times.

Meanwhile, within this unsympathetic climate, the recovering nurses were also attempting to not relapse, to recover
their health, and do the work of their regular nursing job.

Professional Education Practices
Several participants felt strongly that nurses lacked basic
education about the reality that nurses can and do develop
their own problems with substance use, and the warning
signs of the same. According to Rachel,
You should learn about addiction in the health care field to really
understand how prevalent it is because I think that that’s missed
. . . I think if somebody would have told me about it I might have
been a little bit more wary or might have seen my own behaviors
before the narcotics [became] troublesome.

When the topic had been spoken of in participants’ formal
education, the focus was placed on how to report miscreant
nurses to institutional authorities, rather than understanding
lived perspectives or learning about nurses’ substance problems as health issues. As Molly explained, “There’s no
understanding of what it is like to have a disease and how to
help . . . They [just] know how to report.”
Participants expressed their beliefs that nurses, especially
novices, were inadequately prepared in their basic nursing

education to cope with the intense emotional work that they
were required to undertake to manage the many stressors
inherent in their jobs. Work stressors dominated the ways
that participants talked about their substance use and work
lives, particularly the distress that nurses felt from engaging
with the suffering, traumas, and even deaths of their patients.
Pietra shared her experiences of what, in retrospect, she
viewed as a major gap in her nursing education:
I can look back on it now and say that I was not equipped
emotionally to deal with what happens to people . . . We need to
recognize that when we see those horrible events . . . we will need
to work through those feelings and those thoughts about what’s
happened and the resources have to be available so we can be
assisted through that . . . feeling helpless and hopeless, not
knowing where to go to get the proper information of how to help
[our patients] . . . There’s nothing on this [in our nursing
education] except how to make a bed and put a good corner on it
and take vital signs, and you don’t have that, you don’t have that.

Nurses also reported having to cope with numerous other
sources of workplace stress, including heavy workloads;
imposed overtime; fatigue from shift work; musculoskeletal
strain and injuries; verbal, sexual, and physical assault; and
conflicts with coworkers, all of which were overlaid by
unsupportive leadership. Bella articulated how she believed
that a lack of any discussion in her nursing education about
workers’ rights and established standards for working conditions left her vulnerable and unequipped to safeguard her
own health and well-being: “I just didn’t know. I should have
had a course about policies, and union, and that kind of stuff
because I just didn’t have any idea about . . . my rights in the
workplace.”
As importantly, however, several nurses in our study conveyed that the reverse was also true. Participants stated that
learning about their fundamental workers’ rights for safe
working conditions and ways to advocate for these rights
were crucial elements in their successful recovery from substance-use problems. They believed that this education
empowered them to manage their workplace stressors in ways
that better protected their emotional and physical health.

Coping Practices
Our analysis unveiled how nurses carried out the work of coping by practicing silence and/or substance use and how these
practices were managed by discourses within the nurses’
everyday talk about work stressors and substance use.
Coping by practicing silence. Our participants reported implicit
and explicit messages in the way nurses talked, or did not
talk, that organized the conditions for nurses to practice
silence and to actively silence colleagues as they all endeavored to cope with some of the most difficult life circumstances
and pressures embedded in their day-to-day work lives. Helen’s remarks revealed taken-for-granted norms in nurses’

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Global Qualitative Nursing Research

social relations that managed how participants talked or did
not talk about work stressors:
There were comments along the line that . . . “everyone finds
this upsetting, you just have to deal with it” . . . you know, that’s
what the job’s about . . . because if you started to raise anything
that was at all loaded . . . people would be “yeah, that was really
awful, now I gotta go to the bathroom or go do this or go do that
or whatever,” and it wasn’t like people were mean about it. Just
it was kind of like, “Okay, we have enough to deal with ourselves
and we’re done dealing with you too.”

Another participant, Vicki, explained how nurses did not
want to discuss such problems with other nurses, lest they be
perceived as incompetent:
[If a nurse is] not able to cope . . . they have a poor constitution
. . . If you consistently were not able to cope, then you weren’t
cut out for this, and you’d probably be gossiped about [by other
nurses].

Helen’s and Vicki’s comments revealed an assumption
that it is crucial for nurses to silently cope with work stresses
so as to not add to the burden of others, because all nurses are
thought to be working on a razor’s edge and struggling to
cope with themselves. Colleagues’ responses to an individual
expressing distress, as well as the silencing of such expression, create an expectation that nurses are required to be
strong, uncomplaining, and “just suck it up,” as no one has
the emotional, physical, or time resources to pick up another’s “slack.” Nurses consider peers who voice difficulty coping with work-related stress to be deficient, and talking about
such feelings is often perceived as a sign of weakness or even
evidence of unsuitability for the nursing profession.
Coping by practicing substance use. Nurses practiced substance use to cope with work demands in various combinations with talk and silence. Their selections of whether they
practiced silence or talk along with their substance use
depended on the discursive categorizations of the substances
and stressors in question. For example, participants revealed
that nurses did not place any premium on concealing or
silence around their typical practices of liberally self-administering nonprescription over-the-counter medications and
nonpharmaceutical substances that had either stimulant,
calming, antidepressant, pain-relieving, sleep-inducing,
muscle relaxing, and/or mild euphoric types of effects. They
would openly use these to manage physical stressors, such as
pain and sleep–wake cycle disturbances arising from shift
work. This self-medication was often done with a wink and a
nod, and with full knowledge and complicity of nurse colleagues. The lead researcher described how, as a nurse educator, she knew novice nurses to extensively use these types of
substances to cope with work life: “The young nurses especially are self-medicating like mad. Energy drinks, diet pills,
melatonin, St. John’s Wort, Gravol, Benadryl to manage shift

work, take tons of ibuprofen and acetaminophen for pain, all
this over-the-counter stuff” (LRJ). Rosie also illustrated how
she knew other nurses to routinely use their professional scientific knowledge of these substances’ effects to meet the
physical demands of work. According to Rosie, “a lot of
nurses had migraines and they weren’t feeling well, so we
gave them an injection of Gravol in the bathroom . . . to get
you through your shift and that was okay.”
Rosie also explained how it was not at all uncommon for
nurses to pilfer nonprescription medications from their workplaces to enable them to work throughout their shift.
Participants reported that nurses did not look upon the diversion of these drugs as stealing; however, they did understand
that the practice is officially considered to be so. Nevertheless,
we found that nurses’ use of these nonprescription substances
to cope with emotional distress was not spoken of.
Nurses typically remained silent if they used legitimately
acquired prescription drugs, such as opioids, sedatives, anxiolytics, or antidepressants, for either physical or emotional
reasons. This was because nurses reportedly categorically
regarded use of these drugs as a sign of weakness and even
evidence of being a “drug addict.” In describing how nurses
did not talk about their use of such medications, Molly
recounted how she accidentally saw a nurse colleague’s opioid prescription at work: “I know other nurses who were taking way higher doses of pain medication than me and they’re
still working . . . [I saw her opioid prescription in her open
purse] and I thought, ‘Holy shit that’s a lot.’” Nevertheless,
as Rosie described, nurses commonly, but quietly, used those
drugs to cope with emotional distress on a day-to-day basis,
so that they could carry out the requirements of their job:
A lot of nurses are on Ativan [a prescription drug used to treat
anxiety that has sedative effects] at night to sleep, to cope with
the death and destruction that we see . . . [nurses] are more
desperate and coping with your assignment and the sickness of
people in the hospital and the death, it’s horrible.

Many nurse participants also reported nurses frequently
used these types of medications to manage physical pain, so
that they could work, and that their pain often arose from the
conditions of their work. However, stealing drugs in these
categories from the workplace was absolutely not spoken of,
and the nurses who were known to do so were categorically
regarded as reprehensible. Judged worst of all were those
who had taken drugs from their patients. As Pietra recalled,
They cannot understand how you could possibly start filtering the
medication from the hospital to your own personal supply . . .
To use medications that you’re entrusted to give to patients,
because that’s where mine went . . . is horrible.

Participants who had stolen these kinds of drugs from
their workplaces also described how using them had actually
enhanced their ability to carry out their work, by enabling
them to better cope with physical and emotional work

7

Ross et al.
stressors. These nurses were more tolerant with patients and
coworkers because their emotions were numbed. They also
were able to work harder and longer because they could
forgo basic needs to eat and sleep, and they did not utilize
their allotted sick leaves when unwell. As Rachel recounted,
When I was using [opioids], it was quite easy because I could go
for hours . . . I worked the next 21 days straight and I used [the
drugs] every day . . . I actually ended up working more because
at work is where I . . . got my drugs from, so I ended up being a
bit of a workaholic and picking up as much overtime or extra
shifts . . . It made me want to work more and it kept me at work
more than at home.

Rachel described here how, although she was actively using
drugs that she stole from work, she regularly and without complaint volunteered to work extra hours and more successive
shifts than scheduled. Nurses who stole drugs from their workplaces shared their perceptions that their peers had viewed
them as particularly hardworking and dedicated because of
their willingness to work overtime. Unbeknownst to their colleagues, however, they were managing their work lives in specific ways to facilitate access to their supply of drugs.
We found that nurse participants spoke about nurses’
practices of alcohol use altogether differently from other
substances. As Helen explained, participants reported that
nurses’ use of alcohol outside of the workplace was widely
spoken about and tacitly endorsed as a method to cope with
emotional distress, particularly work stressors:
I think to some degree having a drink after work or whatever,
people were, yeah, “I’m going to go home and have a glass of
wine . . . ” . . . People did that to debrief or calm down and that
was sort of chuckled about, but nobody talked about the fact that
if someone kept drinking it would be an issue.

“Partying” or recreational binge-type heavy alcohol use
was reported as common practice and talked about freely in
a light, humorous fashion as a sanctioned way to “blow off
steam.” In fact, alcohol use was the only practice of substance use, or otherwise, that the participants said nurses
talked about openly as ways to manage emotional distress
arising from their work.
The lead researcher’s reflections on her experiences in
many nursing workplaces over several decades highlighted
how nurses talked about alcohol use in a way that served as
an accepted kind of shorthand signaling to other nurses that
they were experiencing stress:
You’d never say, “Oh, I just can’t cope with that death, or the
distraught relatives,” or “I’m so stressed out by the workload I’m
going to have a breakdown.” No, you’d say, “This was a twoglass-of-wine shift!” and everyone would laugh and agree. (LRJ)

Not all manner of nurses’ alcohol use was viewed favorably,
however. Study participants described a taken-for-granted

understanding that it was important to be able to handle their
liquor. If the alcohol use was seen as problematic, or if a
nurse was found to be drinking or intoxicated on the job, the
nurse was disparaged in the same way as those who had
problems with other substances. Regardless, participants
reported that nurses who had problems with alcohol were
looked upon far more sympathetically than those who had
problems with other drugs.

The Work of Managing Disclosure
The paradox of obtaining help for substance-use problems. A
curious contradiction was revealed in the nurse participants’
talk. This was that, as noted prior, under specified conditions, the uses of some substances were implicitly and explicitly endorsed as suitable practices for nurses to utilize to
manage their physical pain and emotional distress. However,
nurses who were believed to have problems with substance
use were judged as morally deficient and incompetent others.
Here, we came to a disjuncture in the data analysis. We did
not understand how, or whereby nurses were seen to have
crossed that line—when did they become that “other” nurse?
When the lead researcher posed this question to the nurses,
they answered clearly—their categorization shifted when
they asked for or evidently needed help. For instance, according to Mark, “I think when you get busted . . . when an individual gets caught . . . or asks for help. Once you’re ID’d
[identified], right?” As Mark articulated, it was at the juncture when nurses sought, or were visibly in need of assistance for problems with substance use that they had received
clear messages both from their peers and their own internalized discourses that they had failed as a nurse.
The work of concealing substance-use problems. The participants were unambiguous in reporting that one of the primary
reasons that nurses concealed their problems and were so
distinctly disinclined to seek assistance was their fear of
being harshly judged by their peers in this way if they admitted needing help. Nurses described how they feared being
outed because the negative way that they and their colleagues
had typically spoken about nurses and others with substanceuse problems had set their expectations that they would be
condemned. Consequently, nurses were typically guarded
about their substance-use problems, and felt compelled to
mask the true nature of their problems from colleagues by
practicing silence and engaging in a great deal of difficult
thought and emotional work to actively conceal their problems from their colleagues.
Many participants reported that when their problems did
become known to colleagues, they needed to undertake a
substantial amount of emotional and interpersonal work to
navigate and cope with a work environment characterized by
a relentless undercurrent of hostility, contempt, and suspicion. Even those nurse participants who ultimately did
receive a positive reception from their peers when their

8
substance-use problems were disclosed reported that they
had gone to great lengths to manage potential disclosure.
Liza described her hesitation in this way: “I personally have
never had anything but amazing support from all my colleagues . . . [but] I can guarantee you I wouldn’t have told.”

Discussion: Silent Angels—Moralistic
and Individuated Discourses Managing
Nurses’ Substance Use
The historical nursing motto, “I see, and I am silent”
(Villeneuve, 2017, p. 24) is now generally regarded as quaint
and somewhat distasteful. Nevertheless, this imperative was
clearly reflected in the present day, whereby nurses’ experiences of work stresses are suppressed, reconstructed, and
replaced with dictates of silent endurance and performance
of duty. These current discursive representations of nurses
readily bring to mind the historical Christian and Victorian,
gendered, moralistic stereotypes of “good” women (and
nurses) as temperate, uncomplaining, endlessly altruistic
“angels” (Heise, 2002; Turkoski, 1995). Our data supported
others’ findings that vestiges of such virtue-based ideologies
persist in current nursing discourse (Gordon & Nelson, 2006;
Kunyk, Milner, & Overend, 2016). Our study also revealed
how substance-use problems were discursively organized as
character flaws that “good nurses” simply do not have. Those
who did were categorized as others, quite separate from and
of lesser social and moral stature than nurses themselves.
Uncovering how these moralistic discourses organized
nurses’ knowledge contributes much-needed depth to the
broad and ill-defined conceptually based explanations in the
literature on nurses’ substance-use practices. Specifically,
this knowledge adds important nuance to the widely used
concept of stigma to describe nurses’ negative judgments of
other nurses who have substance-use or emotional or mental
health problems and their own reluctance to seek help for the
same (Kunyk, 2015; Kunyk, Innes, et al., 2016; Moll, Eakin,
Franche, & Strike, 2013; Parrish, 2017).
Our findings also offer a challenge to the reductive conceptualization in the nursing literature explaining how
nurses’ substance-use problems arise from cavalier attitudes
toward their self-administration of drugs (Kenna & Lewis,
2008; Lillibridge et al., 2002). These data highlight how
nurses’ substance use is linked to the premium placed on
their mute accommodation of punishing working conditions
(from shiftwork and overtime to death and violence). Rather
than possessing faulty “overconfident attitudes,” our participants reported that nurses purposefully leveraged their professional knowledge of substances to numb physical pain
and emotional distress, so that they could meet the discursive
imperative of silent stoicism and continue to work. In this
way, nurses’ substance-use practices often provided their
employing institutions with compliant workers who subsidized the true cost of their work with their own health and
well-being. These data also lent support to Turkoski’s (1995)

Global Qualitative Nursing Research
notion that dominant ideologies of nurses’ “professionalism”
have historically managed their behavior in ways that
deterred them from challenging their employers about poor
working conditions. Another unexpected finding was the
inadvertent institutional utility of nurses working more hours
and shifts than scheduled to access the drugs they acquired
from their workplaces and had become dependent on.
The individuated, moralistic discourses that were found in
nurses’ day-to-day talk are also generalized throughout the
professional and scholarly texts that are intended to provide
nurses with guidance about their substance-use and coping
practices. The clear messages sent in these texts are that the
responsibility for nurses’ coping (or not) with work stressors
is situated entirely with the individual nurse and that substance-use problems are evidence of their personal failure at
this task. The role of the institution in the stressful working
conditions that the nurses must somehow cope with appears
to have been erased from this discursive construction.
For example, a professional resource document intended
to assist nurses with maintaining their “fitness to practice”
(College of Registered Nurses of British Columbia [CRNBC],
2008, p. 13) cryptically advises them to “set limits . . . [as a]
workplace and professional self-care” (p. 13) strategy. In
another text, health care providers are cautioned to not “forget
to take care of themselves . . . say no when needed . . . don’t
over-identify with their patients . . . [and] plan regular breaks”
(Parrish, 2017, p. 147). No direction is offered as to exactly
how a nurse might actually go about doing so in their real-life
working conditions. Advice to distance themselves from their
patients seems irrelevant to the work contexts that our study
participants described, in which they experience great distress
from engaging with traumatized patients to provide them with
competent nursing care. It seems equally unhelpful to instruct
nurses to “take care of themselves” (Parrish, 2017, p. 147)
when the realities of their work, both revealed in our findings
and found in the literature (Shields & Wilkins, 2006), often
involve punishing work environments with imposed overtime
on understaffed units where they are unable to take breaks. It
is also highly unlikely that they would feel safe to “say no”
(Parrish, 2017, p. 147) or to “set limits” (p. 147) when they
have been socialized into the professional norms uncovered
here that dictated silent endurance of work stresses.
Confusingly, this silencing discourse is echoed in that same
document, where nurses are also advised to “avoid chronic
complainers” (Parrish, 2017, p. 147) or to shun colleagues
who do speak up. Nurses are also admonished in resource
texts to “avoid self-destructive coping” (CRNBC, 2008, p.
11), in which problems with substance use are held up as
exemplars of individual nurses’ failure to do so.
Similarly individuated discourses align closely with current trends for workplace wellness programs in health care
institutions. These programs redistribute the job of managing
workplace stressors wholly back to the individual, typically
by offering assistance in the form of “self-help tools and
resources with lifestyle mentoring, or health coaching”

9

Ross et al.
(Preston, 2012, p. 2). Initiatives to actually improve the
nurses’ working conditions or organizational culture are not
part of this workplace wellness package.
One can also see individuated discourse generalized to the
management of nurses at institutional policy levels. For
example, professional programs to manage nurses who have
been identified as having problems with substance use,6 likewise, situate their focus solely on the individual nurse (Ross
et al., 2018). These individuated perspectives are also articulated to broader discourses in the “new public management”
(Rankin & Campbell, 2006, p. 14) administrative approaches
that currently govern Canadian health care organizations. In
that mode of institutional organization, nurses’ work stressors
that arise from corporate efficiency and cost-cutting imperatives “are glossed over as nurses’ ‘constraining beliefs’”
(Rankin & Campbell, 2006, p. 158), thereby eliminating the
institution from the problem, and framing the solution as
“changing nurses’ beliefs and behaviors” (p. 158).
These discourses are also consistent with those found in
the scholarly nursing literature, in which a highly individuated (Ross et al., 2018), neoliberal (Kunyk, Milner, &
Overend, 2016) perspective exists toward nurses’ substanceuse problems, which pays little heed to the institutional context of nurses’ work lives. For instance, Burton (2014)
concluded a common characteristic of nurses who had problems with substance use was that “they did not know how to
effectively cope” (p. 157). Health care professionals are also
counseled to “accept responsibility to modify a lifestyle burdened by stress, chronic overwork” (Storr, Trinkoff, &
Hughes, 2000, p. 1463). Rarely do studies show that nurses
are encountering situations that exceed a normal person’s
ability to cope or that employing institutions should bear
some responsibility for such conditions (Lillibridge et al.,
2002; Ross et al., 2018). Current public health-based
approaches that view substance-use problems as inextricably
connected to the conditions in peoples’ environments
(Rhodes, 2002) are inexplicably absent in the scholarly nursing literature (Ross et al., 2018). Notable exceptions are recommendations to address nurses’ substance-use problems by
mitigating their “traumatic” working conditions (Lillibridge
et al., 2002, p. 226), improving their organizational support,
and creating more positive work environments (Scholze,
Martins, Galdino, & Renata, 2017).
Our participants reported their basic education did not
prepare them with factual knowledge about nurses’ substance-use problems, and that they merely learned, as Molly
said, “how to report” other nurses’ transgressions. These data
were consistent with findings in the scholarly nursing literature that undergraduate nurses receive scant, if any, evidencebased knowledge on substance-use problems in general and
nurses’ in particular (Burton, 2014; Cares, Pace, Denious, &
Crane, 2015), and that the education they did receive took a
highly individuated perspective (Ross et al., 2018).
Our data also aligned with the content seen in professional texts (at the provincial and national levels) on nurses’

substance use (Canadian Nurses Association, 2009; CRNBC,
2017, n.d.) that targeted reporting of colleagues, but did not
offer meaningful information about prevention of or possible
contributors to nurses’ problems with substance use. They
instead addressed the issue by framing nurses as conduits of
potential threats to patients—“nursing is demanding work, in
which impairment could result in direct and significant risk
of injury to patients” (CRNBC, n.d., p. 1)—and directed
their focus toward urging nurses to police and report colleagues’ impaired practice.
These educational deficits left our participants with no
means of understanding or words to talk about their substance-use problems, other than the dominant individuated,
morally centered, othering ways. Their only other alternative
was silence. This crucial gap in nurses’ basic education needs
to be addressed. Furthermore, our study uncovered two
socially sanctioned practices that nurses did use to manage
the stresses in their work lives—silence and alcohol. Alcohol
use was socially organized as both the verbal shorthand that
nurses could use to voice their emotional distress arising
from work and the authorized strategy to cope with it. This
important new finding challenges the considerable weight
afforded to the largely uncontested and taken-for-granted
assumption in the literature (Ross et al., 2018) that nurses’
ready access to prescription drugs is the prime contributor to
their problems with substance use. Indeed, one study found
that an astonishing “one in 20 of the nurses indicated that
their substance use had limited their commitment to patient
care” (Kenna & Wood, 2004a, p. 114), and that the (mostly
women) nurses’ overall alcohol use was disproportionately
high, compared with typical gendered patterns of alcohol use
and that of other health care groups. This predominant over
focus on nurses’ access to drugs has cloaked awareness of a
possibly more serious situation, the largely unexamined role
of alcohol in nurses’ management of their work-life
stressors.

Conclusion and Recommendations
Our study revealed how nurses’ basic education and professional resources did not provide them with ways or words for
understanding their substance-use problems, other than that
of the dominant moralistic and individuated discourse. A
lack of protective knowledge, coupled with a virtue-based
professional identity offered them an illusion of immunity
from substance-use problems. This created a perfect storm
that left them vulnerable to insidious development of substance-use problems, without the awareness that this could
happen to them, let alone be able to ask for help if it did. We
also saw how nurses’ gaining the knowledge and skills to
self-advocate for their improved working conditions was
connected with their recovery from substance-use problems.
Accordingly, we call for educational initiatives to both
raise nurses’ awareness of the moralistic, individuated discourses that they are a part of and provide them with

10
factually based undergraduate and ongoing education about
nurses’ substance-use problems. We also recommend capacity-building initiatives to equip nurses with the knowledge
and skills to advocate for physically and psychologically
safe workplaces. We wish to make clear that these recommendations are in themselves insufficient. To imply so would
be perpetuating the stance that we challenge and continue to
place the responsibility for the issue back on the individual
nurses. Rather, we do so in keeping with the emancipatory
intention of IE. This is to increase people’s awareness of “the
socially organized powers in which their/our lives are embedded and to which their/our activities contribute” (D. E. Smith,
1999, p. 8) and promote their empowerment with the knowledge enabling them to effect institutional change.
We assert that the role of the nurses’ employing institutions in establishing the working conditions, wherein nurses
develop substance and stress-related health problems, is conspicuously absent in the discourse and must be brought to the
forefront of this issue. We uncovered dominant discourses in
nursing regulation, management, and research that subordinated and silenced nurses’ experiences of work stress. Nurses
who deploy their knowledge of substances to silently manage these stressors are discursively organized as deviant individuals and held up as dangers to the public. We contend that
a more critical perspective and empathetic approach must be
taken toward nurses’ substance-use problems and that organizational cultures and management approaches need to shift
in ways that better support nurses.
Our data also added an important new finding—that alcohol use was the only coping strategy that nurses spoke of as
being an acceptable, and even openly encouraged, way to
manage emotional distress. We put forward that this as-yet
underresearched finding of the role of alcohol in nurses’
management of their work stressors merits more intense
scholarly scrutiny.
Shining the light on these dominant discourses found in
nurses’ talk enables nurses to challenge, disrupt, and ultimately transform them in ways that better serve the interests
of all involved—nurses and their families, health care organizations, as well as patients. It is our sincere hope that our
discoveries contribute to that change.
Acknowledgments
We would like to express our gratitude to the nurse participants for
their generosity and courage in sharing their expert knowledge and
experiences in the spirit of helping other nurses. We sincerely hope
that we have done justice to your efforts. We wish to acknowledge
our appreciation to Dr. Dorothy E. Smith for her unfailing generosity in offering us her support, guidance, and wisdom and also
remember the late Dr. Elliot Goldner, who has been with us in spirit
every step of the way in this research.

Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Global Qualitative Nursing Research
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.

Notes
1. In this article, the term substance is used to refer to psychoactive substances, which are those that “affect mental, psychological, behavioral functions; i.e., sensations of pain and
pleasure, mood, consciousness, perceptions of reality, thinking ability, motivation, alertness” (Health Officers Council of
British Columbia, 2011, p. 12). These include the categories of
depressants (including alcohol, opioids, sedatives, hypnotics),
stimulants, cannabis, psychedelics, and psychiatric medications
(Health Officers Council of British Columbia, 2011).
2. We have chosen to avoid the use of such conceptualizations
and instead use the following terms: substance-use problems,
problems with substance use, or substance-use practices.
Although we acknowledge that these could also be construed
as social constructs, our intent is to be descriptive and not connote any category, concept, or alignment with any theoretical
perspective.
3. In her work on the institutional ethnographic mode of inquiry,
D. E. Smith (2005) asserted that individuals experience disjunctures when their own knowledge and experiences are being subordinated to dominant conceptual discourses.
4. In this study, we differentiate our use of the term discourse
from how we use the terms talk and language. Here, talk refers
to people’s “words as uttered” (D. E. Smith, 2017, p. 23) in
speech, and language denotes how people’s words (in talk or
written) coordinate their activities with those of others.
5. The approach to generalization in this study differs fundamentally from that of quantitative research, in which statistical findings are intended to be generalized to populations. We instead
use the traditional IE meaning of the term, which denotes a process whereby local effects are socially organized to reoccur at
other times and in other locations (D. E. Smith, 2005).
6. We have researched one such treatment program for nurses in a
forthcoming work.

ORCID iD
Charlotte A. Ross

https://orcid.org/0000-0002-3668-7647

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Author Biographies
Charlotte A. Ross, RN, RPN, PhD(c), is a PhD candidate in the
Faculty of Health Sciences at Simon Fraser University in Burnaby,
British Columbia, Canada.
Sonya L. Jakubec, RN, PhD, is an associate professor with the
School of Nursing and Midwifery at Mount Royal University in
Calgary, Alberta, Canada.
Nicole S. Berry, MA, PhD, is an associate professor with the
Faculty of Health Sciences at Simon Fraser University, in Burnaby,
British Columbia, Canada.
Victoria Smye, RN, PhD, is the director and an associate professor
with the Arthur Labatt Family School of Nursing at Western
University, in London, Ontario, Canada.