workplace impairment handout - corexcel

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Addiction is a chronic, relapsing disorder characterized by compulsive drug/alcohol seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in rewards, stress, and self-control. Those changes may last a long time after a person has stopped these harmful behaviors. Addiction is a lot like other diseases, such as heart disease. Both disrupt the normal, healthy functioning of organs in the body, both may have serious harmful side effects, and unintentional effects, and both are, in many cases, preventable and/or treatable.

INSIDE THIS COURSE

COURSE OBJECTIVES ................. 1 ABUSE OF DRUGS ...................... 2 WORKPLACE IMPAIRMENT .......... 3 BEHAVIORS OF IMPAIRMENT ....... 4 STEPS FOR REPORTING .............. 6 REPORTING LAWS ..................... 8 SAFETY INITIATIVES .................... 9 TREATMENT APPROACHES ....... 11 SUMMARY ................................ 12 REFERENCES ........................... 13 CE EXAM ................................. 14 EVALUATION ............................ 18

RECOGNIZING IMPAIRMENT IN THE

WORKPLACE 2.0 Contact Hours

Written by: Karen Truman, PhD

Many states have mandated continuing educational credits on recognizing impairment in the workplace for nurses to maintain their licensure. Completing this course will provide nurses with the information needed to promote and provide safe practice, facilitate interventions, and protect their patients if faced with a health care worker who shows signs of impairment. Nurses are pivotal to the surveillance and coordination of the code of ethics to: do the sick no harm. They are critical in establishing and maintaining care cultures in which patient safety is a priority.

This course is designed for all medical professionals who may encounter a coworker who is impaired during working hours. To be able to recognize impairment, one must first understand that there are many types and symptoms of impairment. In addition, it is important to know how to report impaired coworkers, the elements of mandatory reporting laws, initiatives provided by employers to promote safety in the workplace, and treatment programs that are available.

COURSE OBJECTIVES

• Define impairment in the workplace.

• State the different types of impairment.

• Identify behaviors that suggest a coworker may be impaired.

• Outline the vital steps related to referring or reporting impairedcoworkers.

• Discuss the elements of mandatory reporting laws.

• Identify employer-provided initiatives that promote safety in theworkplace.

• Discuss available treatment options.

Online Continuing Education for Nurses Linking Learning to Performance

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Recognizing Impairment in the Workplace

INTRODUCTION

In 2013 in New Hampshire, a hospital worker infected with hepatitis C injected himself with narcotics meant for patients, refilled the syringes with saline, and then administered the contaminated solution to patients. He then infected 46 patients in New Hampshire, and almost 8,000 people over 8 states required testing. Similar diversions are taking place in hospitals across the United States every day (Lockwood, 2017).

Fentanyl is a powerful prescription painkiller, prescribed specifically for people dealing with chronic pain who have developed a tolerance for other long-acting narcotic pain medicines, or for people suffering at the end of life. This medicine is 50 to 100 times more potent than morphine, from which it is derived. One common administration method of Fentanyl is via transdermal patch (the entire sticky side of the patch is a gel which is infused with the medication). These patches are intended to be used for three days, as the medication is slowly released into the bloodstream. Unfortunately, these patches are easily abused, in many different methods. One method of abuse is to remove the narcotic gel from the patch, heat it to melt it, or mix it with water. Then, a hypodermic needle is used to inject the liquid directly into a vein, much like how heroin is used. Fentanyl is far more potent than heroin, and this method of rapid drug onset can also lead to rapid overdose (American Addiction Centers, 2018).

USE AND ABUSE OF DRUGS AND ALCOHOL

When they first use a drug, people may have positive effects to control pain after surgery or an injury. These pain drugs can quickly take over a person's life. Over time, the person has to take the drug just to feel normal. They have a hard time controlling their need to take drugs even though it causes many problems for themselves and their loved ones. Brain imaging studies of people with addiction show physical changes in areas of the brain that are critical to judgment, decision-making, learning and memory, and behavior control. These changes help explain the compulsive nature of addiction.

Did you know that sleep deprivation can produce a decline in performance such as slower reaction times, failure to respond to changes and the inability to concentrate and make reasonable judgments? Researchers say lack of sleep is connected to cardiovascular disease, hypertension, and high blood pressure. It also compromises the immune system, contributes to obesity, and severely impairs mental judgment.

Courtnay Slabaugh, an organizational development consultant for SAIF (The State Accident Insurance Fund, a not-for-profit state-chartered workers’ compensation insurance company in Oregon) stated that: “Being awake for more than 20 hours can be equal to having a blood-alcohol

concentration of 0.08 – the legal limit for intoxication in Oregon” (as well as in Florida) (Slabaugh, 2016, para. 2). She also showed results from a national survey in which 15% of workers reported being impaired by alcohol at work at least once during the year, 9.2% worked with a hangover in the last 12 months, and 7.1% reported drinking alcohol during the workday.

“Substance abuse occurs across all generations, cultures, and occupations, including nursing. About 1 in 10, or 10-15% of all nurses, may be impaired or in recovery from alcohol or drug addiction. Although nurses aren’t at a higher increase risk than the public sector, their overall pattern of dependency is unique because they have greater access to drugs in the work environment” (Thomas & Siela, 2011, para. 1).

About 1 in 10, or 10-15% of all nurses, may be impaired or in recovery from alcohol or drug addiction.



IMPAIRMENT IN THE WORKPLACE DEFINED

Impairment in the workplace has been defined as "...the inability to perform essential job functions and interact safely and effectively with others." There are several different types of impairment, all dependent on the actual cause of the impairment. These causes include psychological, emotional, and/or medical conditions, or other types of health conditions such as drug or alcohol dependency. “Impairment is not about having a bad day, but behavior that is really out of character and alarming to others” (The University of Texas M. D. Anderson Cancer Center, 2007, figure 4). When an employee is unfit for duty, the most likely cause is drug or alcohol abuse or serious (untreated) mental illness.

According to a study from the American Nurses Association (ANA), about 10% of nurses become dependent on drugs, which is right in line with the incidence of drug addiction with that of the general U.S. population. Currently there are almost 3 million nurses employed in the country, which means that there are nearly 300,000 who abuse or are addicted to drugs. Of course, accurate statistics are hard to nail down, because drug and alcohol abuse and addiction often go unreported. Some nursing specialties are at a greater risk of substance abuse because of the emotional and physical toll they take on nurses, and the accessibility of drugs common to the area. Such departments include critical care, oncology, psychiatry, and anesthesia.

Prescription drugs that are commonly diverted and abused include:

• Opioids

• Inhalants

• Amphetamines

• Tranquilizers

• Sedatives

These same nurses are more likely to seek help for secondary physical complaints such as anxiety, insomnia, and depression rather than substance abuse, which is ultimately the underlying problem. In essence, this action ends up allowing the substance abuse to continue, and possibly even results in the nurse receiving prescriptions for additional medications that only end up exacerbating the addiction.

According to The National Council of State Boards of Nursing (NCSBN):

Probably the most common complaint seen at BONs (Boards of Nursing) relates to substance use disorder. Addicting substances, alcohol, prescription or illegal drugs, pose a serious risk to patient care. The behavior that results has far-reaching and negative effects, not only on the nurses themselves but also on those who depend on the nurse for safe, competent care. Substance use disorder among health care providers also creates significant legal and ethical responsibilities for colleagues who work with these individuals. All nurses should be aware of the behavioral changes that can result from substance use disorder as they have a professional and ethical responsibility to report a colleague’s suspected drug use to their nurse manager or supervisor, and in some states or jurisdictions, to the BON. It is also important that nurses are honest about their substance use disorder if asked about it on a renewal application, and this includes any conviction for driving under the influence (DUI or DWI). Even though a DUI occurs outside the workplace setting, it is a criminal conviction and must be reported to the BON.



BEHAVIORS SUGGESTIVE OF IMPAIRMENT

How exactly does an employee who is unfit for duty present themselves? It can often be hard to describe, but many times, you will “know it when you see it”. There is discomfort working with the employee, or feelings of not being able to trust him/her to work safely. Coworkers may refuse to work with him/her, they may complain, or they may even feel threatened by him/her. Inappropriate behavior is often complained about by more than one coworker.

Drug abusers often exhibit similar aberrant behavior. Certain signs and symptoms may indicate a drug addiction problem in a health care professional. Have you observed some of the following signs? According to the Department of Justice, these are some signs to look for:

• Work absenteeism – absences without notification and an excessive number of sick days used.

• Frequent disappearances from the work site, having long unexplained absences, making improbable excuses and taking frequent or long trips to the bathroom or to the stockroom where drugs are kept.

• Excessive amounts of time spent near a drug supply. They volunteer for overtime and are at work when not scheduled to be there.

• Unreliability in keeping appointments and meeting deadlines.

• Work performance which alternates between periods of high and low productivity and may suffer from mistakes made due to inattention, poor judgment and bad decisions.

• Confusion, memory loss, and difficulty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time.

• Interpersonal relations with colleagues, staff and patients suffer. Rarely admits errors or accepts blame for errors or oversights.

• Heavy wastage of drugs.

• Sloppy recordkeeping, suspect ledger entries and drug shortages.

• Inappropriate prescriptions for large narcotic doses.

• Insistence on personal administration of injected narcotics to patients.

• Progressive deterioration in personal appearance and hygiene.

• Uncharacteristic deterioration of handwriting and charting.

• Wearing long sleeves when inappropriate.

• Personality change - mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures.

• Patient and staff complaints about health care provider’s changing attitude/behavior.

• Increasing personal and professional isolation.

“Healthcare workers who are impaired rarely admit to impairment unless confronted, and many take extra precautions to avoid discovery, such as chewing gum or eating breath mints to disguise the smell of alcohol and claiming to have allergies to explain runny nose and bloodshot eyes" (Lockwood, 2017, p. 3). Disguising alcohol in coffee or sodas is one way that alcoholic employees drink at work. Impaired individuals are often in denial about the degree of their impairment, and many often believe that it is under control, despite the fact that it is severely affecting their professional and personal lives. The voluntary report of substance abuse by impaired nurses is highly unlikely. In most cases as in doing so often results



in temporary or permanent loss of a job. In addition, confessing to substance abuse, especially if diversion is involved, may (in some states) result in restrictions or even the loss of a nursing license (Lockwood, 2017).

Because stealing drugs is a felony, nurses who abuse illegal opioids (such as heroin or cocaine) or prescription opioids (such as morphine, oxycodone, or fentanyl), almost always resort to diversion to feed their addiction. Even when confronted, the nurse addict will commonly deny they have a problem; this denial is often done out of shame and/or concern about legal actions against them (Lockwood, 2017).

Signs of Impairment

Behavioral Physical

• Personality changes, mood swings

• Fails to keep appointments or meet deadlines

• Frequent absences and late arrivals

• Has increasing difficulty getting along with family and coworkers

• Wears long sleeves even when temperature is high

• Makes increasing numbers of errors

• Has intense bursts of energy

• Appears visibly intoxicated, high

• Shows resentment of authority

• Takes longer to carry out tasks

• Smells strongly of alcohol or marijuana

• Underperforms and makes excuses

• Refuses drug testing

• Vague health complaints

• Chronic rhinorrhea (runny nose)

• Rapid speech (can also be slurred or unclear)

• Frequent diarrhea

• Track marks

• Excessive drowsiness

• Confusion, memory loss

• Weight loss or weight gain

• Dilated or constricted pupils

• Insomnia

• Sallow skin color

• Bloodshot eyes

• Frequent nosebleeds

• Poor hygiene

• Hand tremors, muscle fasciculation’s (brief, spontaneous contractions affecting small numbers of muscle fibers, often causing movement under the skin)

ABCs of Addiction

A: Inability to Abstain.

B: Impairment in Behavioral control.

C: Craving for drugs or rewarding experience.

D: Diminished recognition of significant problems with behavior or personal relationships.

E. Dysfunctional Emotional response.



STEPS FOR REPORTING

The decision to report “…should be based on observations made by you and others and it must have occurred on the job… (the) decision to take action should also be based on concerns about (the employee’s) ability to function rather than whether or not you believe that (the employee) has a particular medical condition” (The University of Texas M. D. Anderson Cancer Center, 2007, figure 7). Even when there is obvious evidence, nurses, in particular, can be very hesitant to report others, despite mandatory reporting requirements. This reluctance can jeopardize patients, coworkers, and the person who is impaired.

When dealing with the employee, avoid placing a label or diagnosis on them or accusing them of having a specific medical problem (e.g., “I think you have a drinking problem”). For instance, “…you might strongly suspect that he or she has a psychiatric disorder but keep this to yourself and only discuss what has been observed with your employee” (The University of Texas M. D. Anderson Cancer Center, 2007, figure 7).

When you observe signs of possible impairment, take action immediately. Remember, you cannot remove an employee from the job unless there are active signs that the person is unable to function. Also, consider the employee’s job duties when deciding what action to take. Is the employee in direct patient care? Is the job safety-sensitive? There’s a big difference between a secretary having hand tremors versus a surgeon having shaky hands! Obviously, driving a shuttle bus or nodding off while dispensing medications requires immediate attention.

The American Nurses Association (ANA) regards chemical dependence as a major problem and takes a proactive stance. The issues of substance abuse and chemical dependence are clearly addressed in the ANA’s Code of Ethics for Nurses, under “incompetent, unethical, illegal, or impaired practice” (American Nurses Association [ANA], 2001). The code states that a nurse who is aware of such a practice has an ethical obligation to report it. Further, “concerns should be expressed to the person carrying out the questionable practice” before reporting to a higher authority, such as a supervisor (ANA, 2001). The recommended course of action is for nurses to confront colleagues directly about their chemical dependence because peers are among the first to recognize a colleague’s impairment (Smith et al., 1998).

Signs of Diversion

Behavioral Workplace

• Administers more narcotic drugs than other nurses

• Volunteers to administer drugs to others’ patients

• Comes to work early, stays late, volunteers for overtime

• Takes frequent bathroom breaks

• Reports wasting excessive amounts of drugs

• Carries drugs, syringes in pockets

• Increasing personal/professional isolation

• Narcotics records do not reconcile

• Patients do not appear to have relief from pain medication

• Drug choice and/or dosage is inappropriate for patient’s level of pain

• Medications missing

• Medication tampering (broken vials)

• Improper storage of injection supplies

• Excessive time spent near drug supply

• Frequent administration of PRN medications

• Failure to document waste

• Fentanyl patches show tampering or disappear

(Lockwood, 2017, p. 4-5)



“The American Nurses Association (ANA) recommends that colleagues confront impaired nurses directly before reporting to a higher authority, such as to a supervisor or directly to the DOH or IPN (Intervention Project for Nurses), allowing the person the opportunity to self-report” (Lockwood, 2017, p. 6). Nevertheless, research shows that numerous nurses will not confront or report their colleagues for an assortment of reasons:

• Concern about assessing the impairment incorrectly.

• Fear of being legal action against them from their coworker.

• Concern that the report will not be taken seriously.

• Fear of retaliation and repercussions, including physical attacks.

• Concern about being labeled as disloyal to colleagues.

• Fear about endangering the employment of another.

In many workplaces, there are now protocols in place for reporting and/or intervening. If this is the case, nurses reporting possible addictions should follow those protocols. Emergent action is vital if a nurse is noticeably impaired at work (disoriented, altered mental status, smelling of alcohol/drunk, unstable). Nurses who observe such impairments should immediately prevent the impaired nurse from patient interaction, and contact a supervisor. The impaired nurse should be taken to the emergency room for treatment (such as for overdose) if necessary.

The steps to reporting an employee are as follows:

• Observe and document: You may become concerned after a series of observations but have no clear evidence of impairment and are reluctant to file a report that may be incorrect. In this case, you should begin to observe closely and to carefully document questionable behavior, including date, time, witnesses, description of behavior, and any action taken, avoiding subjective statements.

• Share concerns: You can always share observations and concerns with a senior colleague and/or a supervisor so that they can evaluate the situation and determine how to proceed.

• Confront/intervene: You should address concerns directly without accusing or diagnosing but should not expect that the impaired employee will admit to having a problem. You can provide the impaired employee with a brochure about any employment assistance a program that is available.

In a study published in Journal of Nursing Regulation (Bettinardi-Angres & Bologeorges, 2011), the authors state:

Most nurses in our sample (57%) reported that even if they were suspicious that a peer was using drugs or alcohol, they would not want to confront him or her. Commonly cited reasons included: “I would be afraid [the colleague] might react in a way that would harm me”; “I would be fearful of possible retribution or retaliation”; “I would feel like I was being a tattle-tale”; “I wouldn’t want to be the one responsible for jeopardizing [a colleague’s] job”; “I’m not sure I trust my own observations or instincts to confront [a colleague]”; and “I know I’m not

Helping the impaired nurse is difficult, but not impossible. The choices for action are varied. The only choice that is clearly wrong is to do nothing.



an expert in chemical dependence and think it would be better dealt with by someone who is…”

Many of the nurses who said they would be comfortable confronting a colleague had worked a number of decades in nursing. Without hesitation, these nurses said they would confront an addicted nurse and report their observations to a supervisor. Their extensive experience gave them personal knowledge of and regret for not intervening in the past. Other nurses who said they would bring the issue to their supervisor cited the fear of losing their own license and concerns about patient care and safety as their reasons.

If an employee is clearly impaired at work (disoriented, altered mental status, smelling of alcohol, unstable, drunk), then emergent action is required.

The impaired employee must be removed from his or her job duties, especially if their job requires direct patient contact. If possible, ask the employee “…to explain why he or she appears to be unfit for work and document what is said: for example, she might say that she is taking a medication that's causing her to be groggy” (The University of Texas M. D. Anderson Cancer Center, 2007, figure 8).

If necessary, the impaired employee should be transported to the emergency room for treatment (i.e., for an overdose). If there is a medical emergency or the employee is a danger to themselves or others, call 911.

Keep in mind that many workplaces have procedures in place for reporting and/or intervening. If this is the case, the employee or you should follow that protocol.

ELEMENTS OF MANDATORY REPORTING LAWS

Legal aspects to report a substance-abusing nurse vary among individual states, but nurses have an ethical and moral duty to patients, colleagues, the profession of nursing, and the community to take action. Documents such as the American Nurses Association Code of Ethics for Nurses provide a framework for patient safety.

Consider the following:

• Do not ignore poor performance.

• Do not lighten or change the nurse’s patient assignment.

• Do not accept excuses.

• Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy.

The following acts constitute grounds for denial of a license or disciplinary action as specified in Florida 456.072 (2) and 464.0095 (Nurse Licensure Compact):

• Failing to report to the department any person who the nurse knows is in violation of this part or of the rules (see below) of the department or the board; however, if the nurse verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the nurse is required to report such person only to an impaired professionals’ consultant. (“Impaired practitioner program” means a program established by the department by contract with one or more consultants to serve impaired and potentially impaired practitioners for the protection of the health, safety, and welfare of the public).



Statute 456.072 includes:

• Being unable to practice with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material or as a result of any mental or physical condition.

Virtually all states include rules and regulations regarding the use of alcohol and drugs as the basis for disciplinary actions. Diversion of drugs from patients is dealt with particularly harshly. Almost all states also require reporting of health practitioners who are suspected of impairment. These rules and penalties vary from state to state.

The Florida Nurse Practice Act [leg.state.fl.us, 2018] is provided as an example of typical state law in regards to the use of controlled substances and the necessary reporting (Each practitioner should consult the rules and regulations for their own profession.):

• Testing positive for any drug, as defined in statute 112.0455, on any confirmed pre-employment or employer-ordered drug screening when the practitioner does not have a lawful prescription and legitimate medical reason for using the drug.

• Being terminated from a treatment program for impaired practitioners, which is overseen by an impaired practitioner consultant…for failure to comply, without good cause, with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol treatment program.

EMPLOYER SAFETY INITIATIVES

For many years, the most common method of dealing with impaired employees was to fire them. Most often, this just passed the impaired employee on to employers in other facilities or states. For nurses, they were not only fired, but also reported to the Board of Nursing for disciplinary action.

Policies and procedures may be in position to recognize those who need help to overcome impairment. These elements may include:

• Pre-employment drug testing

• Probable cause drug testing

• Mental health evaluation

Florida Statute 112.0455 Definition of Drug

“Drug” means alcohol, including distilled spirits, wine, malt beverages, and intoxicating liquors; amphetamines; cannabinoids; cocaine; phencyclidine

(PCP); hallucinogens; methaqualone; opiates; barbiturates; benzodiazepines; synthetic narcotics; designer drugs; or a metabolite of any of the substances listed herein Florida Statute Drug-Free Workplace Act, 2012, para. (5) (a).



Nurses and other health professionals impaired by alcohol or other drugs pose a serious risk of harm to patients, colleagues, and themselves. Employers have a duty to protect the patient as well as an ethical obligation to assist their employees.

An employer should consider the following guidelines and/or ethical issues. Confidentiality related to information concerning a chemical dependency problem is required by federal law. Each employer should have a policy which includes:

• A cause for testing policy.

• Identification of the person who will interact with the employee concerning their impaired practice.

• A referral process for evaluation and treatment.

• Clear consequences associated with refusing treatment. It is the obligation and responsibility of a colleague or co-worker to document and report an impaired health professional’s behavior to the employer or designated supervisor. The health professional should not be allowed to give patient care until he/she has been evaluated and received treatment.

Nurses are professionals who are highly trained, self-motivated and are often expected to assume leadership roles, therefore they may have great difficulty in acknowledging personal needs. It is common to hear this kind of statement: “I could not reach out for help, because I feared the consequences.”

A nurse should be offered treatment in lieu of termination. It is more cost effective to help the nurse get treatment and return him/her to the workplace than to replace them. It is important to note that the suicide risk is increased after an intervention/confrontation. It is necessary to assure the nurse is not left alone after an intervention until a plan is in place. The nurse also has the right to refuse treatment.

Protocol: Protocols should be developed by each facility for receiving and dealing with reports of impairment and diversion. All staff members should be given this protocol, and it should be reviewed in detail during staff meetings. Review of the protocol should happen when it is introduced, during subsequent orientations, and when the protocol is updated. Intervention actions, reporting and referral options, documentation requirements, and return-to-practice guidelines should be outlined in the protocol(s).

Education: Familiarity with prescribed medications and the administration thereof, combined with lack of adequate knowledge about the progression of addiction, can often lead nurses to self-medicate and then fail to identify the signs of addiction. In addition, this lack of adequate knowledge feeds into the negative connotations of addiction. It should be mandatory for each staff member to attend classes in substance abuse. The classes should include (Lockwood, 2017, p. 10):

• Risk factors for substance abuse

• Physiology of addiction

• Signs and symptoms of substance abuse

• Resources available, including alternative programs such as the Intervention Project for Nurses (IPN)

• Ethical and legal obligations to report

Diversion prevention programs: All nursing staff are usually informed that organizations are focusing on diversion prevention and are carefully monitoring controlled substances as well as other drugs. In addition, the organizations will perform regular audits of automated drug dispenser reports and medical records. Nurses are forbidden to share passwords and/or controlled substance access codes. All staff members should be informed of the signs of diversion, as well as the steps to reporting concerns with a diversion prevention program.



Employee assistance programs: Many types of employee assistance programs (EAPs) are available for all staff members. Some EAPs are associated with the Board of Nursing (such as IPN), while others are associated with professional associates, and still others are unaffiliated. A range of different services are provided by EAPs to help employees cope with stressors that occur both at home as well as in the work environment. Comprehensive services, such as counseling, support groups, and educations are offered by some EAPs, while others may provide a list of resources and referrals. The goals of EAPs are to provide an alternative to disciplinary action to employees who are impaired.

Employee wellness programs: Wellness programs are preventive programs aimed at promoting the health and well-being of employees in areas such as physical activity, nutrition, sleep/rest, quality of life, and workplace safety. Examples may include:

• Smoking cessation programs

• On-site classes on how to get better sleep or how to safely lift/move patients

• Hosting yoga or meditation sessions

• Encouraging participation in programs such as the ANA’s Health Nurse, Health Nation

APPROACHES TO TREATMENT

There are different approaches to treatment which are used with the impaired employee, dependent on the individual person’s needs. With nurses, relapses are common, and this is one of the main reasons that many nurses have 5-year contracts with the IPN. Participating in more than one treatment approach may be valuable. Treatment approaches may include:

Mental health evaluation/treatment: The initial evaluation is generally performed by a psychiatrist or a certified addiction professional who is best able to assess the employee’s need for treatment. Inpatient rehabilitation services and medically-supervised withdrawal may be necessary for some employees. Many times, impaired employees have dual diagnoses (both mental health problems and substance use disorders) so psychiatric treatment may be necessary to stabilize them and address symptomatic issues.

Support groups: In general, support groups vary significantly in makeup. IPN-approved facilitators lead over 150 support groups throughout the state of Florida.

12-step programs: The first step of a 12-step program urges a participant to admit he is powerless to control certain behaviors or addictions. These programs are peer led and everything discussed is considered confidential. Participants at these groups may come from many walks of life, so they are not specific to health professionals.

In-patient rehabilitation: Comprehensive therapy and treatment occurs when impaired employees are hospitalized for various periods of time (usually 28 to 90 days). In a stable environment. A treatment facility may use an effective blend of traditional and alternative therapies that empowers lifelong sobriety and clean-living options.

Cognitive behavioral therapy: CBT is a goal-oriented short-term form of psychotherapy regularly used with impaired individuals to assist them in identifying unhealthy and maladaptive behaviors and thought patterns that is counter-productive and/or interferes with everyday living, perceptions, and reactions.

Motivational interviewing: Motivational interviewing is an evidenced-based counseling approach that health care providers can use to help patients adhere to treatment recommendations. It emphasizes using



a directive, patient-centered style of interaction to promote behavioral change by helping patients explore and resolve ambivalence.

Relapse prevention: Because relapse is very common (40 to 60% according to the National Institute of Drug Abuse), staying clean is an ongoing process. A team of researchers at the National Institute on Drug Abuse (NIDA) has identified what may be the crucial brain circuit involved in relapse to drug use when an effective behavioral treatment for drug addiction, known as contingency management, is discontinued. Contingency management uses non-drug rewards, such as cash stipends, prizes, or coupons for retail goods, to encourage people to remain drug-free. Most patients, however, will relapse when they no longer receive the alternative reward. These findings provide insights into the brain mechanisms underlying relapse after successful contingency management treatment and identify a potential novel target for relapse prevention using brain stimulation methods (National Institute on Drug Abuse, 2017).

SUMMARY

Impaired healthcare workers, such as nurses, are an increasing problem because of the stress of nursing and easy access to patient medications. Risk factors for substance use disorders include genetic psychological, behavioral, social, family, physical, and role-related factors. There are both behavioral and physical signs of impairment. Impaired nurses often resort to diversion, so colleagues must be aware of the behavior signs of diversion and workplace signs. Some states have mandatory reporting laws that require that nurses report other nurses who cannot practice safely because of physical or mental illness or use of alcohol, drugs, or other chemicals. By allowing impairment in the workplace, you are contributing to a harmful or unsafe environment. The impaired nurse must be confronted and reported:

• Observe and document

• Share observations

• Confront/intervene and report

• Nurses may (and should) self-report

The cost associated with chemical dependency is significant. It affects employers, co-workers, clients, family, and the community at large. Absenteeism, accidents, injuries, stress-related illnesses and violence are only some examples that can result if these problems are left untreated. Early recognition leading to intervention and treatment of the chemically dependent health professional is often delayed. The problem(s) may be denied, rationalized or minimized. Coworkers, colleagues, and supervisors may protect, blame, promote, transfer, or even ignore the affected professional. It is difficult to take responsibility to deal with these kinds of issues for many reasons. However, it is a professional responsibility to assist colleagues in recognizing deterioration in job performance, to get assistance and treatment when necessary and to make sure no harm is done to your patients.



REFERENCES

American Nurses Association. Healthy Nurse, Healthy Nation website. (2019). http://www.healthynursehealthynation.org/

American Society of Addiction Medicine. (2019). Definition of addiction. Retrieved from https://www.asam.org/resources/definition-of-addiction

ATrain Education (n.d.). Florida: Laws and rules of nursing. Retrieved from https://www.atrainceu.com/content/5-disciplinary-process

Badzek, L., Mitchell, K., Marra, S., & Bower, M. (1998, December 31). Administrative ethics and confidentiality/privacy issues. Online Journal of Issues in Nursing, 3(3). Retrieved from http://ojin.nursingworld.org

Bettinardi-Angres, K., & Bologeorges, S. (2011, July). Addressing chemically dependent colleagues. Journal of Nursing Regulation, 2(2), 10-17. Retrieved from https://www.ncsbn.org/Addressing_Chemically_Dependent.pdf

Florida Statute Drug-Free Workplace Act, art. 112.0455 (2012).

Intervention Project for Nurses website. (n.d.). https://www.ipnfl.org/

Lockwood, W. (2017). Recognizing impairment in the workplace. Retrieved from http://www.rn.org/courses/coursematerial-10023.pdf

National Council of State Boards of Nursing. (2018). NCSBN welcomes you to the nursing profession. Retrieved from https://www.ncsbn.org/New_Nurse-Booklet-Web.pdf

National Institute on Drug Abuse. (2017). Study identifies a brain pathway involved in drug relapse after cessation of contingency management. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2017/10/study-identifies-brain-pathway-involved-in-drug-relapse-after-cessation-contingency-management

National Institute on Drug Abuse. (2018). Drugs, brains, and behavior: The science of addiction. Retrieved March 2, 2019, from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drug-misuse-addiction

Redmond, J. (2017). Nurses and substance abuse: How access can lead to addiction. Retrieved from https://summitbhc.com/nurses-and-substance-abuse-how-access-can-lead-to-addiction/

Slabaugh, C. (2016). The latest buzz: Workplace impairment. Retrieved from https://www.saif.com/safety-and-health/workplace-impairment.html

The University of Texas M. D. Anderson Cancer Center (Producer). (2007, September 24). Impairment in the Workplace; Supervisor Actions [Podcast transcript]. Retrieved from https://www.mdanderson.org/transcripts/Impairment_Text_edited_9_27_07.html

Thomas, C. M., & Siela, D. (2011, August). The impaired nurse: Would you know what to do if you suspected substance abuse? American Nurse Today, 6(8). Retrieved from https://www.americannursetoday.com

United States Department of Justice, Drug Enforcement Administration, Diversion Control Division. (n.d.). Drug addiction in health care professionals. Retrieved from https://www.deadiversion.usdoj.gov/pubs/brochures/drug_hc.htm



1. What percentage of the nursing workforce does the American Nurse Association (ANA) estimate may be impaired or in recovery from alcohol or drug addiction?

A. 5 - 10%

B. 10 - 15%

C. 15 - 20%

D. 25%

2. Impairment in the workplace has been defined as the inability to perform _____ and interact safely and effectively with others.

A. At your best

B. Cardiopulmonary resuscitation

C. Essential job functions

D. Another’s job duties

3. When an employee is unfit for duty, the most likely cause is drug or alcohol abuse or serious untreated mental illness.

A. True

B. False

4. Prescription drugs that are commonly diverted and abused include:

A. Opioids

B. Sedatives

C. Inhalants

D. All of the above

5. Disguising alcohol in coffee or sodas is one way that alcoholic employees drink at work.

A. True

B. False

CE EXAM

RECOGNIZING IMPAIRMENT

IN THE WORKPLACE



6. Some behavioral signs of impairment include all of the following EXCEPT:

A. Personality changes, mood swings.

B. Wears short sleeves even when temperature is low.

C. Takes longer to carry out tasks.

D. Vague health complaints.

7. Some physical signs of impairment include all of the following EXCEPT:

A. Excessive bursts of energy.

B. Chronic rhinorrhea (runny nose).

C. Sallow skin color.

D. Poor hygiene.

8. Some behavioral signs of medication diversion include all of the following EXCEPT:

A. Volunteers to administer drugs to others’ patients.

B. Takes frequent bathroom breaks.

C. Comes to work late, leaves early.

D. Reports wasting excessive amounts of drugs.

9. Some workplace signs of medication diversion include all of the following EXCEPT:

A. Narcotic records do not reconcile.

B. Drug choice and/or dosage is inappropriate for patient’s level of pain.

C. Failure to document waste.

D. Infrequent administration of PRN medications.

10. When dealing with a staff member, it is okay to place a label on them or attempt to diagnose their problem.

A. True

B. False

11. The decision to report an employee for workplace impairment should NOT be based on:

A. Observations made by you and/or others.

B. Observations made off the job.

C. Concerns about the employee’s ability to function.

D. Whether or not you believe the employee has a particular medical condition.



12. When signs of impairment have been observed, you should take action immediately to remove the employee from their job if necessary. Things to consider include which of the following:

A. The employee shows active signs they are unable to function.

B. The employee is in direct patient care.

C. The job is safety-sensitive.

D. All of the above

13. Elements of mandatory reporting laws for Florida include all of the following EXCEPT:

A. Failing to report workplace impairment jeopardizes a nurses’ own license, unless the nurse verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition.

B. Testing positive for any drug, on any ordered drug screening when the practitioner does not have a lawful prescription and legitimate medical reason for using the drug.

C. The definition of “drug” does not include alcoholic beverages, including distilled spirits, wine, malt beverages, and intoxicating liquors.

D. Being unable to practice with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material or as a result of any mental or physical condition.

14. Employers may have policies and procedures in place to recognize those who need help to overcome impairment. These elements may include:

A. Probable cause drug testing.

B. Seizure of personal effects.

C. Required annual physicals.

D. Exit interview drug testing.

15. Treatment approaches for the impaired employee must always include in-patient rehabilitation.

A. True

B. False

16. The contracts that nurses have with IPN last for how long?

A. 2 years

B. 3 years

C. 5 years

D. 10 years



17. Relapse prevention programs help clients do which of the following?

A. Identify triggers.

B. Avoid making plans for dealing with relapse.

C. Give into cravings.

D. Avoid having to use their support system.

18. When an organization is focusing on diversion prevention, which of the following are true?

A. Nursing staff are not usually informed.

B. Organizations carefully monitor only controlled substances.

C. Regular audits of automated drug dispenser reports are performed.

D. Medical records are not typically audited on a regular basis.

19. According to the National Institute of Drug Abuse, relapse is not very common.

A. True

B. False

20. Research has found that it is more cost effective to help the addicted nurse get treatment and then return him/her to the workplace that to replace them. All of the following are true EXCEPT:

A. A nurse should be offered treatment in lieu of termination.

B. It is necessary to ensure that a nurse is not left alone after an intervention until a plan is in place.

C. The risk of suicide is not increased after an intervention/confrontation.

D. The nurse has the right to refuse treatment.



Continued on Next Page

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EVALUATION

RECOGNIZING IMPAIRMENT

IN THE WORKPLACE



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UNDERSTANDING IMPLICIT BIAS

The goal of healthcare is to provide the best possible care to all patients; indeed, many healthcare professionals must recite a pledge similar to the Hippocratic oath upon licensure. However, it is possible for healthcare professionals to have implicit bias that leads to substandard care.

Implicit bias is an unconscious attitude leading to stereotypes that influence thought and action. Not being aware of this bias can lead to unintentional discrimination in patient assessment and diagnosis, treatment, follow-up care, etc. Discrimination, unconscious or otherwise, in these impacted areas of healthcare leads to disparities where disadvantaged patient populations receive unequal care. Patient groups especially at risk of receiving unequal care may include:

Those with lower income Women Minorities Those who speak English as a second language The elderly

An example of healthcare disparities can be seen in breast cancer mortality rates. Black women are 41% more likely to die from breast cancer than white women. Additionally, they are less likely to be diagnosed with stage I breast cancer, but twice as like to die from early breast cancer.

Eliminating implicit bias can help reducing disparities in healthcare. Strategies for healthcare professionals to remove bias from their practice may include:

Regulating emotions – being aware of, and control, thoughts and feelings Building partnerships – working with patients to achieve a common goal Taking perspective – understand the patient perspective during all phases of healthcare

Recognizing implicit bias and working to remove it from practice will help healthcare professionals to give the best care possible to all patients and reduce the disparities between patient populations.

REFERENCES

Alspach, J. Implicit bias in patient care: an endemic blight on quality care. Crit Care Nurse (2018) 38 (4): 12–16.

Aujero, M. Breast cancer screening for at risk women. Oral presentation at: 23rd Annual Breast Cancer Update; February, 2021; Wilmington, DE.

Narayan, M. CE: addressing implicit bias in nursing: a review. Am J Nurs (2019) 119 (7): 36-43.


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