Administration & Leadership – Impairment in the Workplace: Substance Abuse
The purpose of this course is to help nurses in the state of Florida identify and support colleagues who may be afflicted with workplace impairment.
- Identifying the signs of impairment in the workplace
- List employer initiatives to promote safety and provide assistance
- List essential steps to make a report or referral of an impaired nurse
- Discuss the mandatory reporting law
- Discuss treatment programs for impaired practitioners
Impairment occurs when a nurse is unable to provide safe patient care due to using a mood or mind altering substance, having a physical condition or a distorted thought process from a psychological condition (Intervention Project for Nurses, 2015). Due to one of these conditions the nurse is unable to perform their professional responsibilities and duties consistent with nursing standards.
Drug and alcohol use is a significant problem and it is estimated that 10 to 15 percent of all nurses may be actively impaired or in recovery from drug or alcohol addiction (Thomas & Siela, 2011). In addition, it is estimated that 29% of full-time workers engage in binge drinking, 8% engage in heavy drinking and 8% have used illicit drugs in the past month (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007).
Substance abuse is seen in all areas of nursing, but it is most prevalent in the intensive care unit, post-anesthesia unit or emergency department (Angres, Bettinardi-Angres, & Cross, 2010).
Nurses need to be aware of the impact impairment has on the patients and the health care system in general because the impaired nurse may not be able to provide safe and appropriate care. It is critical that nurses are aware of signs of impairment and how to report a fellow nurse suspected of substance abuse.
Some impaired nurses will function well, but some may provide poor patient care, make medication errors and/or divert controlled substances from a patient to themselves. In addition to poor work performance, there is the potential for damage to the nurse’s health. Substance abuse has the potential to lead to mental illness, cardiovascular disease, hypertension, liver disease, hepatitis, human immunodeficiency virus, traumatic injuries and possibly death due to over dose.
According to the Florida Nurse Practice Act (NPA), some actions surrounding drug and alcohol use are grounds for the denial of a license or disciplinary actions (The Florida Nurse Practice Act, 464.018 – Disciplinary actions). These activities include:
- Sale,distribution or possession of a controlled substance
- Not being able to perform nursing duties with reasonable skill and safety due to illness or use of alcohol, drugs, narcotics or chemicals or any other type of material or as a result of any mental or physical condition. Probable cause must exist to believe that the nurse in not able to practice nursing due to the impairment. The suspected impaired nurse has to submit to a mental or physical examination to a physician and this can be enforced by the circuit court after a petition is filed. The accused nurse is given an opportunity to show he/she can resume competent nursing practice at reasonable intervals.
- The board should not reinstate the license of a nurse who the board has found guilty on three different instances for violations for using drugs or narcotics when the offense included drug or narcotic diversion from the patient to the nurse.
Signs of Impairment in the Workplace
Substance abuse comes in many forms. It may involve street drugs, alcohol abuse or taking a prescription of either a patient, family member or friend. Nurses may take some injectable medication from a patient to use for themselves and give the patient a diluted down version of the drug or pure saline. Medications frequently abused by nurses include: alcohol, benzodiazepines, cocaine, methamphetamines, marijuana, narcotics, sleeping pills, heroin, ecstasy, and stimulants.
While many nurses have a long history of drug and alcohol abuse, some nurses going through a stressful time may use substances to cope their problems.
The impaired nurse may be difficult to detect, because they often are very careful to avoid being caught. By the time signs or symptoms are noticeable it is often been going on for an extended period of time.
Addiction is a compulsive behavior and may stem from abuse, an unstable lifestyle, a family history of addiction, poor choices, thrill seeking or denial. Treatment of addiction should be done for an extended period of time. The willingness of the nurse and the length of treatment are the strongest predictors of success (Thomas & Siela, 2011). Often, nurses resist substance abuse treatment; and only enter a program with the encouragement of family, friends, peers, management or a court order.
Signs and symptoms suggestive of substance abuse include:
- Medication and documentation errors
- Poor work quality
- Leaving work early or arriving late
- Difficulty meeting deadlines or schedules
- Excessive use of sick time
- Poor charting
- Many mistakes
- Absences from the unit
- Mood changes after breaks
- Rounding at odd times
- Suspicious attitude toward others
- A large number of wasted narcotics
- Not performing narcotic counts
- Frequent report of patients not getting adequate pain relief
- Maximal use of as needed pain medications for their patients
- Offering to medicate other nurse’s patients
- Obsession with narcotics or the Pyxis machine
- Discrepancy between the narcotic record and patient record
- Altered orders
- Unexplained need for money
- Increased narcotic sign outs
At times, physical signs may be noticed in an impaired nurse. Some physical signs that should increase the suspicion of impairment include:
- Slurred speech
- Watery eyes
- Constricted or dilated pupils
- Unsteady gait
- Frequent runny nose
- Diminished alertness
- Weight gain or loss
- Change in appearance
- Frequent use of gum, mints or mouthwash
- Frequent nausea, vomiting or diarrhea
There are certain behaviors that should clue the nurse that a co-worker may be impaired and include:
- Poor concentration
- Outbursts of anger
- Mood change
- Wearing long-sleeves when short sleeves are appropriate (to hide tract marks)
- Poor judgment
- Frequent pain complaints
- Hypoactivity or hyperactivity
- Frequent accidents
Employer Initiatives to Promote Safety and Provide Assistance
Substance abuse disorders are a major problem in nursing. Substance abuse disorders lead to more deaths, disabilities and illnesses than any other preventable health condition (NIDA, 2007). While abuse affects up to 15 percent of nurses, it may be partly beyond the nurse’s control, genetic factors account for 40-60 percent of an individual’s susceptibility to addiction (NIDA, 2008).
Substance abuse contributes to missing work, injuries, reduced productivity, liability, societal harm, person harms and increased health care costs. It is beneficial, not only for the employee, but also the employer to assist their workers in managing alcohol and substance abuse.
Nurses lack education regarding the addiction process, how to identify those with addiction and how to implement effective interventions. It is important that nurses receive education about substance use disorders. Employers can have significant impact in improving the nurse’s knowledge and attitude toward substance abuse.
Employers should implement strategies to promote safety and provide assistance. Guidelines should be developed to promote safety for nurses and their patients and offer assistance to nurses who suffer with substance abuse or other conditions that lead to impairment.
Policy should be a drug free work place and having all nurses fit to practice. Practices that will reduce the risk of impaired nurses on the worksite include: pre-employment drug testing, for cause testing (testing when there is logical suspicion that the employee is under the influence of drugs while working) and fitness to practice evaluations.
The workplace should promote a culture of transparency and consist of clear expectations and consequences. In addition, it should be clear that there is openness to help the nurse with a substance abuse problem or other condition that leads to impairment.
The workplace has significant potential to identify and help workers with drug and alcohol problems. Workers spend a lot of time at work and co-workers and supervisors may be able to notice signs or symptoms of drug or alcohol problems and assist them in getting the help they need.
Employers may influence employees to get help for impairment. Many employers have employee assistance programs (EAP) and/or educational program to help prevent drug or alcohol problems or other causes of impairment. Programs may include health promotion, education, and referral to alcohol and other drug abuse treatment if needed. These programs look to quickly identify problems and intervene early.
Drug or alcohol problems are often identified in the workplace when there is a poor-quality of work, attendance problems, when an employee self-refers to an EAP or when a co-worker identifies a drug or alcohol problem in another worker (Roman & Blum, 2002).
The primary goal of an EAP is to help employees maintain their job and career. While these programs are not free and may cost the employer significant money, research suggests that EAP provide more savings than it costs. The U.S. Department of Labor reports that 5 to16 dollars are saved for every dollar spent in an EAP. This is done through a 75% reduction in inpatient substance abuse and alcohol treatment programs; a 65% reduction in accidents occurring on the worksite; a 66% reduction in absenteeism related to alcohol abuse and a 30% reduction in workers compensation claims (Preferred Employee Assistance Program & Behavioral Health Services, 2010).
While it is not illegal to drink alcohol, the effect of drinking off the job can effect on the job performance. For example, binge drinking may lead to hangovers the next day which may compromise work performance. Employers do have a reason to attempt to modify employee drinking as this may positively affect work performance. Hangovers increase the risk of bad judgment, injuries, impair motor or cognitive function and reduce work productivity (Roman & Blum, 2002).
The ideal way to address off the job drinking is through alcohol education programs at work through EAP or another health promotion program with the goal of encouraging behavioral change. This may even encourage the patient who is impaired to self-refer themselves to treatment programs.
Alcohol education programs also have the potential to teach workers to identify an impaired co-worker. A nurse who works alongside another nurse is more likely to identify problem behaviors before a supervisor notices the same problem behaviors.
Health promotion programs are often put on by employers to help motive their employees to change behaviors. Drinking and drug use can affect health; teaching employees about healthy alternatives has the potential to change behaviors. For example, engaging in exercise, adapting a healthy diet or taking up a stress management program may reduce drug or alcohol use.
Risk factors in the work environment for alcohol and drug use include: stress, alienation and a culture of drinking within an organization (Roman & Blum, 2002). Chronic work stress, a large number of hours worked, unhealthy work conditions and poor workplace safety is linked to alcohol related problems (International Center for Alcohol Policies, 2015). The employer has a responsibility to determine if risk factors are present within the work environment and attempt to modify the work environment to reduce the risk of alcohol and drug use.
Addressing alcohol and drug use in the work setting has many similarities to addressing it in primary care. Both the worksite and the primary care office have significant preventative potential. Much variability exists between the content and quality of interventions between health care settings and places of employment. Unfortunately, there is the potential to hide problem behaviors and unless the health care provider or the worksite finds a problem no intervention will occur. Both the primary care setting and worksite have many roles to fulfill and preventing, identifying and treating substance and alcohol abuse is not the highest priority goal in either setting.
Employers may resist intervention in prevention programs for multiple reasons including (Roman & Blum, 2002):
- Concern that reducing alcohol problems will be costly and only benefit the individual and not the employer
- A concern that prevention programs may suggest the employer is contributing to drug and alcohol abuse
- Concern that those treating alcohol or drug use will not have the workplace’s best interest in mind and will be unreasonable, costly and impede work productivity.
EAP assist substance abuse programs within companies. It is estimated of worksites with over 100 employees, 66% have EAP programs and ninety percent of Fortune 500 firms have a similar program (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007). EAP programs are not solely derived to address substance abuse, they also help employees with other issues such as mental health, marital problems, parenting problems, financial problems, legal issues and balancing life and work. They offer visits to provide assessment or short-term counseling. Employees may be referred to an outside provider for follow up treatment.
Employees may not get involved in EAP for a variety of reasons. Employees often do not feel that their problems will be held confidential, but they are confidential. Many employees may also feel shameful for looking for help. Some employees fear that they need to get permission from their boss, but they can self-refer to an EAP. Lastly, many do not know that they exist.
When looking at EAP outcomes, the majority of studies suggest that they provide positive economic benefits and improved work and clinical outcomes (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007).
Some workplaces more strongly promote EAP than other workplaces. Factors that contribute to enhanced use of EAP include: employee awareness, supervisor training, belief in EAP, willingness to use EAP and when EAP are promoted optimistically in company policy (Levy-Merrick, Volpe-Vartanian, Horgan, & McCann, 2007).
Individuals who use a company EAP are more likely to take part in and stay engaged in alcohol and other drug treatment programs. Factors associated with greater use of EAP include: major depression, black race/ethnicity, or any drug use disorder (Jacobson & Sacco, 2012).
Determining impairment from mental illness is a tricky task. A scale, the Nurses Work Functioning Questionnaire, has been developed to determine if there is impairment from common mental illnesses. It is a 50 question survey that has been determined to be highly reliable and valid. The survey includes seven subscales that predict the exact aspect of impairment and helps in determining interventions to help the impaired nurse (Gartner, Nieuwenhuijsen, van Dijk, & Sluiter, 2011).
What to do if a Nurse Suspects another Nurse is abusing?
The first step the nurse must do to be able to report an impaired health care provider is to be able to recognize the signs or symptoms and be educated in substance abuse. Many nurses fear reporting a colleague because they worry about retaliation.
Nurses should be able to notify the nurse manager of their suspicions as this is in the best interest of the nurse and the nurse’s patient. Nurses should be familiar with the organizations policy for employee substance abuse and any assistance programs that the organization offers.
A fellow nurse should not enable another nurse to continue to abuse substances. Enabling the nurse can happen when the substance abusing nurse’s poor performance is ignored, excuses are accepted, or the nurse making assignments gives the impaired nurse an easy patient assignment. It is the ethical duty of the nurse to report any substance-abusing nurse (ANA, 2015).
While the ANA is not in favor of random drug tests for nurses, if there is concern that drugs or alcohol is affecting work performance it believes that testing is appropriate (ANA, 2015). In addition, the ANA is against the misuse of prescribed drugs by nurses. It also is opposed to the misuse of prescribing drugs by nurses who have prescriptive authority. It encourages nurses to have pharmacological education about abuse, misuse and addiction of prescriptive drugs (ANA, 2015).
Steps to Make a Report or Referral
It is not helpful to make excuses or cover for an impaired nurse. It will not only potentially harm the nurse, but his or her patients. The nurse should be made to accept the consequences of his or her behaviors and actions. Any impaired nurse should be reported immediately to prevent any negative effects to the nurse, the nurse’s co-workers or patients. Reporting a colleague can be a positive step as this will protect patients and support their colleagues to enter into treatment programs.
It is critical that nurses guard against behaviors that promote impairment among fellow nurses. The nurse should not ignore signs of impairment or engage in enabling an impaired nurse. The impaired nurse should not just be fired or transferred as this passes the problem on to another department or employer and continues to put patients at risk.
The requirements for mandatory reporting of nurses by nurses vary from state to state. When a nurse observes a colleague doing something suspicious, it is the nurse’s role to report it to a supervisor. In the state of Florida, any person who suspects a nurse is impaired must report the nurse to the Intervention Project for Nurses (IPN) and/or Florida Department of Health. To make a referral to the IPN and/or confidential consultation — Call the IPN at 1-800-840-2720.
The Intervention Project for Nurses (IPN) is meant to enhance public health and improve safety by offering an opportunity for quick intervention/close monitoring and support for nurses whose practice may be weakened from the use, misuse or abuse of alcohol or drugs or a mental/physical condition (Florida Nurse Practice Act, Chapter 455.261).
A nurse who cannot practice safely due to impairment is in violation of the Nurse Practice Act. The IPN offers a program for impaired nurses to be rehabilitated in a non-punitive and confidential method. The goal is to keep nurses practicing instead of allowing them to lose their license. The IPN will allow early intervention to expedite enrollment into a recovery program. The nurse immediately stops practicing and does not return to practice until the IPN assures that they are safe to return to practice. It offers a cost-effective method to the disciplinary process. If the nurse is reported to both the Department of Health and the IPN at the same time then disciplinary action may occur.
Any individual who believes the nurses ability to provide safe care is compromised due to impairment may report the nurse to the IPN and/or the Department of Health. In Florida there is a Mandatory Reporting Law that requires a licensed nurse to report any suspected impairment to the IPN and/or the Department of Health.
Prior to 1983, the only option the Florida Board of Nursing had was to discipline the impaired nurse and stop them from practicing. Despite the punishment, nurses continued to have problems after their license was reinstated. As the number of nurses who were impaired increased, other options were sought to help get nurses back to work while maintaining safety for patients (Intervention Project for Nursing, 2015).
The impairment of nurses became such a significant problem that the Florida Board of Nursing passed new legislation in 1983 that allowed a new method to address the impaired nurse. The Nurse Practice Act (Florida Statutes 464.018 1k) states”Failing to report to the department any person who the licensee knows is in violation of this part of the rules of the department or the Board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.”
This opened an avenue to provide another option instead of discipline to the impaired nurse. The program that eventually became known as the IPN was established in 1983.
The IPN offers many benefits including protection of the public. They allow the impaired nurse to be recognized earlier and interventions are implemented quicker. The IPN refrains the nurse from practice within 1-3 days, while the disciplinary process through the Department of Health takes up to a year before action is taken. The IPN also evaluates the nurse in a comprehensive, standardized method and offers approved providers and programs that offer treatment. The IPN also provides monitoring for the nurse and involves the employer in the rehabilitation process. The IPN program will more quickly identify a potential relapse and have the potential to offer intervention before severe negative consequence occur (Smith, 2013).
If the nurse is referred to the IPN, it is initiated with a referral call. Next, there is an intake. The suspected impaired nurse is offered interventions. The nurse can agree to the interventions or not agree to the interventions. If the nurse does not agree to the interventions or does not make any progress with the interventions, he/she will be reported to the Department of Health. If the two parties agree and the nurse makes progress in treatment, the IPN will continue to monitor the nurse for 2-5 years (Smith, 2013).
The IPN offers multiple benefits including (Intervention Project for Nursing, 2015):
- Implementation of an IPN contract
- Evaluations on progress
- Suitable referrals
- Random urine drug screens
- Recovery support
- Support groups
- Relapse prevention groups
- Determines fitness to practice
The IPN determines fitness to practice by assessing the nurse’s judgment, problem-solving abilities, stability in recovery, support systems, decision making capacity, coping ability and cognitive function (Smith, 2013).
The IPN also determines when the nurse can return to practice. Criteria the IPN uses to determine if the nurse can return to practice includes that the treatment must be done and the nurse is engaged in the continuing treatment principles such as involvement in a support group. A signed advocacy contract must be received. The nurse must agree to random urine drug screens. The nurse must agree to any practice restrictions that have been set in place. Examples of restrictions may include: agreeing to not having multiple jobs, not working in certain settings such as home health or hospice or working no overtime. Someone to monitor workplace performance will be available to provide feedback. The nurse must have a relapse prevention workbook (Smith, 2013).
Satisfactory progress is determined when the nurse has good monitoring reports, negative drug screens, is in compliance with the individualized advocacy contract and regularly attends monitoring or support groups. Monitoring reports are supplied by the nurse in recovery, the employers, the support group facilitator and the treatment provider (Smith, 2013).
Successful completion of the program includes a validation of progress and stability of the nurse. In addition, fitness to practice is established. After the program is successfully completed, the record is sealed (Smith, 2013).
If the nurse does not progress appropriately, does not comply with program stipulations or stops treatment, the IPN will report the nurse to the Department of Health (Intervention Project for Nursing, 2015).
The IPN does not provide the evaluation or treatment but will offer referrals to professionals to help with addiction. The referral from the IPN can be made to a psychiatrist, addiction specialist or other health care provider in a region close to where the nurse lives.
It does not cost money to participate in the IPN, but the nurse pays for the evaluation and treatment from the specialists and pays for laboratory evaluations and random drug tests (Intervention Project for Nursing, 2015).
What must Nurses Do?
Nurses should know how to document concerns and recognize essential steps in making a report or referral to the IPN or the Department of Health. Nurses should:
- Educate themselves on signs of impairment
- Observe job performance
- Look for patterns in co-workers
- Learn how to document
- Include: date, time, any objective data and any witnesses
- Know when to discuss concerns with a supervisor
- Discuss with the impaired nurse how the impairment affects job performance
- If immediate impairment is present, question the nurse along with a colleague – refer to IPN and/or Board of Health; always intervene with a colleague
- If a nurse is impaired at work, it is important to provide transportation home for that nurse
Planning an intervention is the first step in getting an impaired nurse help. First, the behaviors that are suggestive of impairment should be well documented. The staff should document concise, objective, clear and factual data along with the place, time and date. Once enough documentation is present, an intervention with the impaired nurse should occur. The intervention should ideally occur with a nurse manager and other witnesses – often a group setting is used. The impaired nurse will often deny their impairment.
If issues are not addressed up front, problems have the potential to be buried and impairment will increase as others will cover and hide the co-workers impairment. Impairment that is not addressed up front has to potential to place patients at risk.
Treatment Programs for Impaired Practitioners
Many options are available to help the impaired nurse get help. Many State Nurses Associations have peer assistance programs to assist impaired nurses get referrals to counseling. In addition, many State Boards of Nursing have alternatives to disciple for the impaired nurse. This may include a peer assistance program that includes monitoring and support of the nurse in an effort to get them back to being able to practice nursing safely. The American Nurse Association has an Impaired Nurse Resource Center to assist the impaired nurse.
In the State of Florida, according to Rule 64B31-10.001, an approved impaired practitioner program is chosen by the Department of Health with a consultant to commence intervention, suggest evaluation, and refer impaired practitioners to a treatment program or provider. In addition, they monitor the development of the impaired practitioner. No medical services are provided.
The treatment program has to be nationally accredited or state licensed. The program must have a multidisciplinary team that typically manages the patient in either an intensive outpatient or a partial hospitalization setting. The treatment provider is approved by the impaired practitioner program and must be a state licensed or nationally certified provider with experience managing the particular type of impairment that is effecting the nurse.
Case Study 1
Holly is a 34 year-old nurse, the mother of two young children, who has worked on the night shift of a cardiac step-down unit for the last four years. Over the last three weeks her appearance has gone from neat and clean to wearing outfits that have not been washed and her physical appearance has deteriorated. When her co-workers work with her they notice that she often seems dazed.
Her unkempt appearance and her behaviors were considered by co-workers to be secondary to stress from working full time on night shift and raising two young children during the day. No one suspected that she was abusing substances. One of her co-workers said, “How could a responsible nurse and mother do that?”
One of Holly’s co-workers approaches and tells her that she is concerned about her behaviors. Grateful for someone to confront her, Holly confesses that she has been drinking excessive amounts of alcohol to cope with the stress of her two young children, working full time and having a husband who works long hours and is often out of town. She even admits to drinking before her shift.
With the help of their supervisor, they decide to report to the IPN. The IPN sets up a consultation and based on this consultation a treatment provider is suggested. She sees this treatment provider and goes though counseling sessions for one month. In addition she attends weekly nurse support groups.
After three months, Holly is doing much better and the IPN determines that she is safe to go back to nursing after she signs the advocacy contract and takes her relapse prevention workbook. One of the conditions of her return is that she must attend weekly support groups and maintains random drug screens for the next two years. Restrictions for her include she must remain at her current job and is not allowed to float or take any overtime. Lastly, a workplace monitor is set in place that will provide feedback on her performance.
Case Study 2
David is a 43 year-old nurse who works the night shift in a correctional setting. He is good friends with many of the correctional officers and often goes out with them to a local bar after he gets off shift in the morning.
Lately, he has been calling off work more often and when he is at work the nurses he works with have noticed the quality of his work has been deteriorating and has made multiple documentation errors. He also always volunteers to do segregation pill pass which is an opportunity for him leave the medical unit with the medication box. When he comes back from his segregation pill pass he is always in a much better mood.
He has been written up three times for sleeping on the job. It has also been noticed that he has lost about 15 pounds over the last 3 months.
One of his co-workers suspects that he is using drugs and fills out a form to refer him to the IPN. The IPN does a consultation and determines that he has a problem and works with him to develop interventions to assist him in addressing his issues.
After three months, he decides that he no longer has a problem and drops out of the IPN program. He is immediately reported to the Department of Health. The Department of Health implements an investigation and determines that not only is he abusing alcohol, but he has been stealing tramadol and snorting it to get a high at work. It is also suspected that he may be selling tramadol, codeine and gabapentin to inmates in exchange for money from the inmate’s families.
Legal proceeding ensues and he loses his license. In addition, his place of employment decides to pursue criminal charges on him.
Impairment is a significant problem and may affect up to 15 percent of nurses. It has the potential to not only affect the health of the nurse, but may adversely affect patient care. Nurses are often the first individuals to pick up on another nurse’s impairment. It is therefore critical that nurses are aware of signs and symptoms of impairment.
Many resources are available to help nurses with impairment. Worksites have programs, such as the employee assistance program. In the state of Florida, it is the duty of the nurse to report any impaired nurse to the IPN or the Department of Health.
The IPN offers alternatives to help nurse combat their impairment, help get them back to work and monitor them for relapse. The Florida Department of Health may impose discipline on the nurse if they determine that they are impaired.