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One woman's effort to understand the problem of nursing and addiction

Marie Manthey
MinnPost photo by Sarah T. Williams
Marie Manthey, pioneer of the primary nursing model of care, mentor to nurses and to those in recovery.

Marie Manthey is celebrating 78 years of life, 37 years of recovery, and 50 years as a nursing administrator and care-delivery consultant. Her work is never done, not even now in semi-retirement, and she’s more than OK with that.

No. 1 on her to-do list these days is helping to found a nonprofit peer-support group for nurses who are struggling with substance use disorders. "Minnesota is far behind other states in establishing peer-support organizations for recovering nurses," she said. (The articles of incorporation are to be voted on soon, so that’s all she’ll say about that project for now.) Though nurses are not statistically more likely than the general population to become addicted (about 1 in 10 for both), they have unusually high-risk and high-stress environments, easy access to painkillers, and “privileged access” to vulnerable people.

Manthey, who is credited with helping to found the Primary Nursing (“relationship centered”) model of care at the University of Minnesota in the 1960s, has dedicated much of her life to understanding both the problem and the privilege.

She makes no excuses for those who violate trust (some of whom were highlighted in a 2013 Star Tribune series): “The issue of diverting and modifying the amount of pain reliever that the patients get because the nurse is addicted is totally unconscionable,” she said in an interview Tuesday. “It’s a serious offense, and society sees it that way.”

But she is a strong advocate for more education for nurses (especially about the risks of painkiller addiction), and for peer support programs. “There’s physicians concerned for physicians, pharmacists concerned for pharmacists ... accountants, dentists.” Why not nurses for nurses?

Any solution must begin with a deeper appreciation of the nature of nursing, said Manthey, who pointed out that in spite of those who transgress, nurses invariably are at the top of the Gallup Poll’s annual survey of “most honest and ethical” professionals.

“So why do [patients] trust us?” she asked. “My answer to my own question is because they know they are vulnerable when they see us, especially in the hospital. When they come in the hospital, everybody experiences vulnerability, at almost every level of their being — mental, physical, spiritual, emotional. ... And within the framework of that universal vulnerability, they give us access. And at any time of the day or night, we get to go into those rooms, and we have the opportunity to interact with them in a way that alleviates pain and increases their comfort. We have the knowledge, the skill, the job, the license, the role, and the access. To me that’s the privilege of nursing. And we just have to really understand better ... the essence of that privilege.”

Color her vulnerable

Manthey’s education in vulnerability began when she was just 5 years old during a month-long hospital stay for scarlet fever at St. Joseph’s in Chicago. Her parents had never been inside a hospital and knew nothing of what to expect. “All they could tell me in preparation was that I was going to a big building,” she said.

Visiting rules were strict: One parent, for one hour, twice a week. There were long stretches when Manthey saw no one. To make matters worse, each time her parents came, she was given painful intramuscular blood injections. “I was feeling abandoned, scared, vulnerable, and then when I did see my parents, rather than feeling cared for, I had a lot of pain. That was the environment.”

Into this environment came Florence Marie Fisher, a nurse who knelt by Manthey’s bed one day and colored in her coloring book. It was a small gesture, but one with lasting impact.

“I never saw her again. But she has always been a huge part of my life experience. That feeling of being cared for in the context of my vulnerability was so important that it has been a driving force in my life, and it really drove a lot of choices that I made about what I would concentrate on in my professional life.”

'Relationship-based care'

Manthey went on to earn her undergraduate and graduate degrees in nursing at the University of Minnesota, where she also took her first job in nursing administration. From her perspective, the nursing delivery system was too fragmented and diffuse — one in which “everybody’s responsible for everything so nobody’s responsible for anything.”

In its place, she introduced and developed the Primary Nursing model, which emphasizes “relationship-based care”: one nurse takes responsibility for one small group of patients, delivering individualized care for the duration of the stay.

Said Manthey: “It not only put a relationship focus on the nurses’ role, it also had the effect of decentralizing power and empowering the individual nurse at the bedside.” To support this empowerment, “nurse managers and directors and vice presidents had to really make a considerable shift in their job focus — from control to development.”

As her work responsibilities grew exponentially, so did her duties at home. Manthey now had a newborn and a 5-year-old, and a husband who was “a full-time student and had been for a long time — a professional student so to speak.”

A second child, she said, “was not just an addition of one to the complexity of life. It was an algorithmic increase in complexity.” When she got home from work, the kids were begging for their mother’s attention, there were always “dirty breakfast dishes in the sink,” and she had “always forgotten to take the meat out of the freezer.”

The clamor became unbearable, she said, and a martini “made it all better.”

Looking back, she says she can trace all the invisible lines she swore she’d never cross.

One martini became two

An occasional martini before dinner became a martini every night before dinner. One before-dinner martini became two before-dinner martinis. “I remember telling my husband that the wonderful thing about martinis is that they only taste good before dinner. And then I had one after dinner. And so it went. And it progressed and progressed,” until she was drinking every night to the point of blacking out or passing out.

“Along the way, [my husband] said he didn’t want to be married anymore.”

The troubles didn’t stop Manthey’s career trajectory — not yet, anyway. Drinking heavily and single-parenting, she arrived in 1976 at the prestigious Yale-New Haven Hospital in New Haven, Connecticut, to take a job as vice president of patient services.

There came a time when she could no longer hide her situation. “I was beginning to get puffy,” she said. “They tell you that vodka doesn’t smell, but when you drink enough of it, it comes out your pores. I’m sure that my judgment by this time was probably impaired somewhat if not a lot. It didn’t show up in clear ways in an administrative position — so much of administration is impaired judgment anyway.” (Here she laughs out loud, flashing a wonderfully untamed sense of humor.)

Within a few years of her arrival, the executive team intervened to get her into treatment at Silver Hill in New Canaan. She bargained desperately for outpatient treatment, worried about her children, now 11 and 16. But it would be six weeks of inpatient or lose your job, she was told.

While in treatment, she was fired. The reasons were vague, she said. “I probably could have shot holes in [the firing] if I’d had wanted to. But I was so sick that I just didn’t want to take on a fight. I had two children to support, and I had no savings.”

Taking back the reins

After leaving the protective bubble of treatment, Manthey needed to reinvent herself. The options were few in New Haven. After being fired, going to work at the other hospital in town would not be an option. So she started by writing the book she’d been putting off: “The Practice of Primary Nursing” (‪Blackwell Scientific Publications‬, ‪1980‬).

She then created Creative Health Care Management, a solo consultancy specializing in the delivery of nursing services in acute and long-term care facilities. She wasn’t all that keen on working independently. “I didn’t want to be a consultant. I didn’t want to be a businesswoman. I didn’t want to charge for what I knew I liked to give away. I love to help [organizations] figure out how to do it differently without it being about money.”

In 1978, she brought her solo business back to Minnesota, and built a team that today includes 30 consultants and adjunct consultants who offer tools for “transformational change” within health care organizations. Manthey retired in 2000, but keeps a hand in as a part-time adviser and still gives public presentations nationally and internationally.

She had early on formed a theory about why some who are drawn to the field of nursing might be “predisposed” to addiction:

Even before I really had any experience or understanding of substance abuse, I saw that nursing has a problem with dependency. This is sort of a cultural problem for women: depending on others to take care of them and to help them feel good about themselves, being very concerned about being a people pleaser ... do people like me? All of these issues are really symptoms of dependency, and that began to be real clear to me in my work in trying to empower a nurse to take responsibility for the care of a small group of patients, and to have that responsibility to be visible within the system.

There’s a way in which I see nursing as culturally co-dependent, and medicine historically being addicted to power. And so therefore the fit was perfect [laughs].

The tendency, the fertile ground, so to speak, is right there. Seventy percent of us come from families where one parent is an addict. We come from the rescuers and the martyrs in the family systems dynamic theory ... and we flow toward nursing naturally. These are not consequences, they are not cause-and-effect, but they are predispositions.

And just in the past year, Manthey said she began to see some parallels between recovery and empowering nurses.

In recovery, we learn how to be responsible for ourselves, to not blame others for what’s going on, to be in healthy relationships. And many of the same dynamics that work in recovery ... apply as part of a developmental program to facilitate the independence and interdependence of nurses. So as we move from a dependent profession into full-fledged professional independence and interdependence for collegial relations, the processes are similar to the process of recovery from substance abuse.

A problem, and some solutions

Manthey, who isn’t afraid to challenge and revolutionize whole systems, cannot consider a problem without also offering a solution. Here, in her words, are some of her suggested approaches to the problem of nurses and addiction.

  • Education: It goes this very simple way: Patient has pain. Nurse administers pain med. Patient’s pain is relieved. It’s a very straightforward thing, and it’s very much the nurse’s role. Now you take a nurse who has just lifted an obese patient. She has strained her back. She’s having trouble with working without pain. She’s got the same situation. Patient has two Percocets. Patient says “I’ll just take one today.” So here she sits. It’s already out of the computerized distribution systems. It’s in her hand. It’s absolutely the easiest thing in the world to pop that in and get some relief. And nobody along the way is saying, “That’s the beginning. You’re using a substance for pain relief that is not legitimate.”

  • Stress management: Especially in hospital-based nursing, the stress level due to the direction the health-care system is going, is really, really challenging to control. ... We don’t teach people that nurses’ work is never done. It’s always unpredictable and it’s always out of our control. We need to understand that as natural and not as something that if we work hard enough we can fix. We’ve never had enough nurses, and we never will. If anybody thinks it’s going to get better, they’re smoking funny grass.

  • Prevention: We have to be able to help nurses get help sooner rather than later. And that’s not happening. There’s tremendous fear of losing their license, and that’s a logical consequence of misusing that trust. We have to be able to get them the help that they need without the threat of losing their license as a natural [immediate] consequence of getting help. Once they are getting help and ... are in a monitoring program, we need to support them to stay in that monitoring program and get back into the workplace without fear of being judged.

Manthey knows what it means to violate trust — the especially terrible consequences. But for all nurses, the “vast majority” who are vigilant and the minority who need help, she keeps the faith. About nursing, she said:

“You can’t charge for it. You can’t document it. You can’t count it. There’s no metric that fits those moments of privilege to touch a vulnerable person. And yet that is the core of nursing. That is the legacy. That is the imperative.”

***

MinnPost: “So your work is never done?”
Manthey: “No, it’s just starting! Do I ever know that, my friend.”

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