EMPLOYER INFORMATION  

• Management of Impaired Practice
  

  Chemical dependency is defined as a chronic, progressive, and sometimes fatal disease with stages and a predictable course. Nursing practice impairment is characterized by the inability to carry out professional duties and responsibilities in a reasonable manner, consistent with acceptable standards. Impaired practice is not a new concern to the nursing profession. Since the early 1980s, it has been recognized as a common and serious problem. Although estimates of prevalence vary, the American Nurses Association estimates that between six to eight percent of nurses are affected by substance abuse/dependence to the extent that job performance is impaired. This rate is consistent with that of the general public.

  The Nurse Manager has a fundamental role in the early recognition of impaired practice. Due to the potential negative impact on patient safety, all impaired practice must be addressed proactively. In order to be proactive, one must be adequately prepared for the task at hand. Take a few moments and reflect on the following questions:

• How Prepared am I?
  

  · Do I: Have a basic understanding of addiction and impairment in the workplace?
  · Know the most common indicators of substance abuse nursing practice impairment?
  · Have knowledge of my workplace policy and procedure, related to nursing impairment?
  · Does my workplace have such a policy? Know my resources in-house and externally, with
    whom I can confidentially consult regarding impairment in one of my nursing staff?
  · Recognize my attitudes about substance abuse conditions, as supportive, or as a barrier
    to helping a colleague?
  · Know how to document a problem properly?
  · Feel confident in my intervention skills?
  · Know my reporting responsibilities (hospital administration, Board of Nursing, State
    Alternative/Peer Assistance Program)?
  · Feel comfortable coordinating a re-entry process for one of my staff nurses returning to
    work post treatment?
  
  

• Recognition

  Nurse Managers must become knowledgeable regarding the most common indicators of a problem and they also have a professional responsibility to educate their staff about signs of impaired practice. When signs are witnessed in isolation, many may be indicative of increased stress. However, when observed as a pattern, a more serious situation warranting corrective action is at hand. Even a single indicator may be significant enough to warrant immediate intervention. These signs requiring immediate intervention may include the smell of alcohol on one's breath, and other overt indicators such as staggering gait, slurred speech, witnessed diversion of drugs, and/or any serious error in nursing care.
  
  Signs of impairment generally fall into three (3) major categories of: job performance, personality and mental status, and diversion of drugs from the workplace.  

• Warning Signs of Chemical Dependency

  Job Performance
  · Excessive use of sick time, especially following days off
  · Absence without notice or last minute requests for time off
  · Long breaks or lunch hours
  · Frequent or unexplained disappearances from the Unit
  · "Job shrinkage" - the nurse increasingly does minimal work
     necessary for the job
  · Increased difficulty meeting schedules or deadlines
  · Sloppy or illegible charting
  · An excessive number of mistakes - frequent medication errors, or errors of judgment in
    patient care
  · Smell of alcohol on breath
  · Excessive use of breath mints, chewing gum or mouthwash
  · Elaborate implausible excuses for behavior
  
  Personality and Mental Status
  · Emotional lability - the nurse becomes unusually quiet or irritable or has frequent mood
    swings
  · Inappropriate verbal or emotional responses, such as snapping at colleagues,
    uncontrolled anger or crying
  · Diminished alertness (perhaps appearing dazed or pre-occupied), confusion, or frequent
    memory lapses
  · Increasingly isolates himself/herself from co-workers (eats alone, avoids informal staff
    gatherings, or requests transfer to the night shift)
  
  Diversion
  · Consistently volunteers to be the "medication nurse"
  · Often signing out more controlled drugs than co-workers
  · Frequently reporting medication spills or other waste
  · Failing to obtain co-signatures
  · Reports reflecting excessive use of prn medications
  · Discrepancies in end-of-shift medication counts
  · Evidence of tampering of vials or medication counts
  · Evidence of tampering of vials or other drug containers
  · Waiting until alone to open the narcotics box or cabinet, or disappearing into the
    bathroom after opening it
  · An increase in patients' complaints of unrelieved pain
  · Defensiveness when questioned about medication errors
  · Consistently coming to work early and staying late
  · Volunteering to work with patients who receive regular or large amounts of pain
    medication

• Initiating Action

  Before initiating action, it is best to review facility policy and procedure. Solid policy and procedure is essential to insuring patient safety and the consistent management of impairment issues. Without clearly stated, facility-wide policy and employee education, responses to problems are likely to result in inconsistent and unsystematic management. A haphazard approach places patients, employees, and the entire institution at risk.
  
  Although specific language of policies and procedures may vary from facility to facility, a comprehensive policy for addressing fitness to practice concerns should encompass the following areas:
  
  · pre-employment and probable cause drug testing
  · fitness to practice evaluations
  · documentation expectations
  · intervention procedures
  · in-house and external reporting requirements
  · return to practice guidelines, including relapse management
  · reviewing your own policy and procedures is essential, prior to initiating an intervention
  
  Facilitating an intervention is uncomfortable enough, but without adequate documentation it is almost impossible. The importance of proper documentation cannot be over-stated. Instruct your staff to record clear, concise, objective, factual data when documenting concerns. The date, time, place and situation of concern should always be documented. For example: "On May 17, 2008, Davis Jones was observed sleeping on duty between 10:00 to 10:30 p.m. When awakened, he appeared drowsy, but continued his charging until shift change."
  
  Ongoing documentation will assist greatly should counseling for corrective action be necessary. Proper documentation is crucial to a successful plan of action, especially in the case of chemical dependency impairment, with its subtle progression and chief characteristic of denial. Consulting an expert can also be a great resource for Managers. The need for strict confidentiality in such situations cannot be over-emphasized.

• Tips for Intervention

  Once it is determine that sufficient documentation exists to support concerns of impairment, an intervention should be planned. The planning and participating in an intervention is often another critical responsibility of the Nurse Manager. When doing an intervention, it is important not to just "react" to a situation, but to develop a careful "plan of action" (intervention) before implementation. Usually, the first step is to secure help. In fact, it is never recommended to do an intervention alone, no matter what your confidence level. There are two (2) primary reasons for this. First, the support and the witness of one or two others is useful. Also, a group style intervention is a much more powerful message and, therefore, more successful than an intervention facilitated by an individual alone. Remember denial is the chief characteristic of all addictive diseases; therefore, it is unrealistic to expect the nurse to ask for help. A solid denial system is part of the active disease of addiction. Understanding this will help lower frustration and decrease any expectation of "an instant acknowledgement of a problem". It is more common for the impaired nurse to deny the problem, but demonstrate willingness to comply with an evaluation process, in order to safeguard his/her employment and career.
  
  The intervention should focus on documented facts of performance concerns, along with supportive communication. The objective of the intervention is to request that the nurse refrain from practice and obtain a fitness-to-practice evaluation as soon as possible. Often it is very helpful to contact your state alternative program, prior to the intervention, for additional guidance.

• Intervention Do's and Don'ts

  DO'S	DON'TS
  · Prepare a plan · Review documentation · Request help from others · Decide who will present what · Ask nurse to listen to all that is said before allowing   him/her to respond to interveners · Stick to job performance · Have evaluator options ready · Expect denial · Report as necessary to state alternative program or   Board of Nursing · Debrief with interveners	· Just reaction · Intervene alone · Try to diagnose the problem · Expect a confession · Give up · Use labels

   

• Return to Practice

  A recovering nurse's return to practice also requires planning, and the oversight of this process by the Nurse Manager is indispensable. There are many things to consider, once a nurse is determined safe to return to practice. These include developing return to practice guidelines, often written in what is known as a return to work agreement. Also, experts advocate initiating a return to work conference to provide support, review expectations (including any practice restrictions), monitoring requirements and to answer any questions.
  
  The prospect of returning to work is anxiety-provoking for the recovering nurse, and often the Nurse Manager as well. Discussing the plan for return to work prior will decrease misunderstanding and potential problems later. Those participating in a return to work conference may include (besides the recovering nurse and Nurse Manager), an EAP, Human Resources staff, support colleague/buddy and/or treatment representative. The written return to work agreement should be prepared and copies made for each person present at the meeting. The National Council of State Boards of Nursing (NCSBN) recommends that return to work contracts stipulate clear expectations.
  
  · the length of the contract
  · the plan for treatment (if the contract is signed at the time the nurse's dependency is first
    detected), and Aftercare
  · practice restrictions, such as prohibiting administration of narcotics for a period of time
    (usually 6-12 months), and no overtime
  · the nurse will be required to submit to random drug screening
  · the nurse must attend a support group for nurses
  · the nurse's job performance must meet professional standards
  · provision for periodic evaluation meetings with the direct Supervisor
  · steps to be taken in the event of relapse
  · consequences of failure to comply with contract stipulations

Practice restrictions can be managed in a number of creative ways. A system for labor exchange is one example. This allows for specific tasks to be "exchanged" ahead of time with a designated "buddy", who will be assigned to work in tandem with the recovering nurse. Often, the recovering nurse is prohibited from administering narcotics early in the return to work process. Utilizing a labor exchange would allow a "buddy" to administer all narcotics for the recovering nurse while she completes one of the buddy's tasks previously agreed upon. An arrangement like this removes the burden of extra duties by others to accommodate the returning nurse. Most staff are willing to help and "exchange duties". Teamwork is promoted. Feelings of shame, of being different and/or not carrying a full load are lessened for the returning nurse.

Another important area to consider when preparing for a nurse's return to work is the response of co-workers. If the identified nurse is returning to the same Unit, staff members are probably already aware of some of the circumstances precipitating his/her leaving. As a way to minimize rumors, it is useful to set up a time to openly talk about staff members' concerns. Questions can be answered in a general way to provide "need to know" information to staff members, while at the same time insuring confidentiality. This may be an appropriate time to initiate staff education as well. Basic education on impairment in the nursing profession and its prevalence can help dispel myths of those who view chemical dependency as a moral issue or weakness, rather than a medical illness. Once the nurse returns to work, additional meetings may be useful for further sharing and education. Meetings like these are usually well received. Staff members observe firsthand a caring and professional approach to a colleague who is returning to work post treatment.

In general, the ongoing management of the returning recovering nurse should be no different than that of other employees. In addition, however, the Nurse Manager must also participate in the development of the return to work agreement, and the subsequent return to work conference. She must also compile written performance summaries should the recovering nurse be participating in a state-wide monitoring program.

It is important not to expect "perfection", as it may take the nurse a little while to regain her comfort level upon return to work. Open communication providing support, clear expectations, and regular feedback on job performance is crucial to the nurse's success.

• Relapse Considerations

Chemical dependency is a chronic illness. Like other chronic illnesses, it is characterized by periods of remission and exacerbation. In general, the rate of relapse among nurses is lower than in the general population. This is due to the growth of supportive programs and strict state monitoring programs. Still, some nurses do relapse. Knowing how to manage relapse in the workplace is crucial for both the safety of patients and wellbeing of the nurse. A relapse is essentially a recurrence (exacerbation) of active disease. The signs of relapse mirror the signs of impairment described earlier under "Warning Signs of Chemical Dependence". If relapse occurs, signs will become apparent and will progress without intervention. In recovering nurses, there is usually a behavioral change noted before a break in abstinence occurs. Behavioral changes include such things as taking on more than one can reasonably handle, over-extending, withdrawing from recovery support people and meetings, isolating, resumption of denial thinking and eventual substance use.

The same rule of thumb for usual employee performance assessment applies here. The Nurse Manager should continue ongoing monitoring of job performance, document concerns and take action when warranted. Any concerns must be addressed proactively. If performance concerns do not improve after performance counseling, or if serious signs are observed, steps to re-evaluate the nurse's fitness to practice and to remove the nurse from practice should be initiated. Once re-evaluation is completed and fitness/stability is assessed, next steps can be determined. It is important that this entire process be handled in a non-punitive way. With early recognition of relapse signs and appropriate intervention/treatment, the chances of the nurse re-entering recovery (remission) are great. Once the nurse is stabilized and fitness to practice is determined, the decisions about return to practice can be made. A clear policy regarding the management of relapse is extremely important and it should address areas of identification, documentation, intervention, referral for fitness to practice assessment/treatment, and parameters for return to practice. For confidential consultation and more information, please contact Intervention Project for Nurses (IPN) at (1-800) 840-2720.