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Impairment in the Workplace: Substance Abuse

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Thursday, June 13, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

This course aims to help healthcare professionals identify and support colleagues who may be afflicted with workplace impairment.

Objectives

By the end of this activity, the participant will be able to:

  1. Identify five signs of impairment in the workplace.
  2. Compile employer initiatives to promote safety and provide assistance.
  3. Develop essential steps to make a report or referral of an impaired nurse.
  4. Explain the impaired provider mandatory reporting law in Florida.
  5. Outline the steps a nurse should follow to report or refer an impaired co-worker.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Raymond Lengel (MSN, FNP-BC, RN)

Introduction

Impairment is the inability or impending inability to deliver safe, professional activities and responsibilities because of a behavioral, mental, or physical condition associated with drugs or alcohol. (Toney-Butler & Siela, 2022). Due to these conditions, the nurse cannot perform their professional responsibilities and duties consistent with nursing standards. Drug and alcohol use is a significant problem; one survey showed that 18 percent of nurses demonstrate signs of substance abuse, and 6.6 percent of all nurses suffer from substance use disorder (Trinkoff et al., 2022). Nurses who work in home health/hospice suffer the highest rates of prescription-type drug misuse, at 19 percent, and 15.8 percent of nurses working in the nursing home suffer from substance misuse (Trinkoff et al., 2022).

Another survey demonstrated nurses in long-term care, on medical-surgical units, and in-home health care is most likely to be impaired (Mumba et al., 2019). Nurses working in education and research are less likely to suffer from substance use. Staff nurses, nurse managers, and administrators are 9 to 12 times more likely to suffer from substance use disorder when compared to researchers or educators (Trinkoff et al., 2022).

Substance abuse is stigmatized, inhibiting nurses from seeking help for substance abuse issues. Many nurses suffering from substance abuse are hesitant to continue in the health field due to the pressures of continued monitoring, required attendance in support meetings, and restrictive schedules (Trinkoff et al., 2022). Substance use is often a mechanism to cope with stress or watch peers cope with stress (Trinkoff et al., 2022).

Substance Use Disorder

Substance use disorder (SUD) is a complex condition where uncontrolled use of a substance is detrimental. SUD is a broad term encompassing the uncontrolled use of many substances. Assessment for SUD includes taking an inventory of the patient's drug use, including the type of drugs, the amount, and frequency. In addition, any consequences of drug use should be explored. A complete assessment includes interviewing the patient and family members and previous medical reports. In addition, the clinician should evaluate the patient's desires to change and their stage of change. A complete medical evaluation may include medical, surgical, psychiatric diseases, laboratory evaluations, and family and social issues.

To improve honesty when taking an assessment, a drug history assessment should be done in a non-judgmental way and started by asking about socially acceptable substances and then moving to illicit drugs. Ask about caffeine, nicotine, tobacco, alcohol, sedatives/hypnotics, stimulants, opioids, marijuana, cocaine, heroin, hallucinogens, and inhalants. The clinician should question any "other" substances, as many novel substances (such as bath salts and synthetic cannabinoids) are used.

In addition to the type of substance used, ascertain the use pattern, last use, frequency of use, and quantity used. The clinician should identify the route of drug use (e.g., oral, inhalation, injection, intranasal). Invasive delivery routes suggest a more severe disorder potentially complicated by more severe complications (e.g., injection use associated with hepatitis/HIV and intranasal use associated with infectious disease and sinus perforation).

The spectrum of substance use provides a framework for understanding how to classify the individual's risk. The range includes abstinence, low-risk use, risky use/at-risk use/hazardous use, and harmful use. The consequences increase as the patient moves up the spectrum. Abstinent individuals are at no risk from substances and will not have consequences. Individuals classified as low risk have more risk than those who are abstinent, but the consequences are still relatively low. No use of opioids is considered safe.

Unhealthy use defines the next step on the substance use spectrum. Unhealthy use is where the individual places themself at risk and may start to notice some consequences of substance use. When an individual gets to the harmful use stage, substance use disorder is recognized, and substance use disorder is classified as mild, moderate, or severe.

A screening test for other drugs should include a single question in primary care, validated as a brief screening test. The question is, "how many times in the past year have you used an illegal drug or a prescription drug for non-medical reasons?" This question is just as sensitive and specific as a drug abuse screening test, where an affirmative response has 100 percent sensitivity and is 74 percent specific for a drug use disorder (Smith et al., 2010).

Individuals with substance use disorder suffer from work habit changes, family tension, or conflict. Nurses may also demonstrate poor job performance, charting errors, mood swings, and patient disputes (Webster, 2022). In nurses, risk factors for addiction include a history of physical/emotional trauma, family history of substance abuse, or stress. Stressful events commonly seen in the nursing environment include nurse-to-patient ratios, staff shortages, shift work, elevated workloads, and mandated overtime. Nurses in critical care environments suffer from dealing with patient deaths, erratic workplaces, and being required to work outside their scope of practice (Webster, 2022).

The Impaired Nurse

The impaired nurse presents a significant challenge in the clinical environment. Impaired nurses risk poor patient outcomes and possible punishment, including license revocations. The number of impaired nurses may be underreported as co-workers often fear reporting colleagues.

The International Nurses Society and the Emergency Nurses Association developed a position statement on substance abuse in nursing (Strobbe & Crowley, 2017). It includes:

  • The promotion of an alternative-to-discipline method to treat the impaired nurse with the goal of retention, rehabilitation, and reentry into practice.
  • Education to nurses about alcohol/drug use, diversion, impaired practice, and the creation of policies and procedures to foster a safe, supportive, drug-free work environment.
  • Develop a system and a means to report presumed and definite concerns related to substance use.
  • Promote the view that personal use of drug diversion is a symptom of severe disease and not a crime.

Nurses need to be aware of the impact impairment has on patients and the health care system in general as the impaired nurse may not be able to provide safe and appropriate care. Nurses must be 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 or divert controlled substances from a patient to themselves. In addition to poor work performance, there is potential damage to the nurse's health. Substance abuse can lead to mental illness, cardiovascular disease, hypertension, liver disease, hepatitis, human immunodeficiency virus, traumatic injuries, and possibly death due to overdose.

Nurses often work while under the influence of a substance. In Texas, the three most common substances leading to enrollment in a substance abuse program include opioids, alcohol, and stimulants (Mumba et al., 2019). One survey found that 10% of nurses worked under the influence of alcohol and 6% under the influence of another drug (Pezaro et al., 2021). Many nurses do not feel safe seeking help, with 27 percent of nurses feeling as though they should seek help but did not due to shame, fear of repercussions, lack of perceived support, stigma, and practicalities (Pezaro et al., 2021).

One survey showed that 37 percent of nurses are concerned about a colleague's substance use (Pezaro et al., 2021). Most nurses feel obligated to report an impaired nurse, but many barriers exist. A strong culture exists around the ethical dilemma of reporting an impaired colleague (Pecoraro et al., 2021).

In Texas, impaired nurses are referred to a peer assistance program, a monitoring program, or recovery (Mumba et al., 2019). Referrals occur for multiple reasons, including impairment or diversion from patients. In Texas, 2% of nurses are referred, with 32% relapsing while in the program and 41% finishing the program. Two predictors of relapse in the impaired nurse include having substance use disorder as the referral type and alcohol being the primary drug of choice (Mumba et al., 2019).

Addiction treatment includes many options, including medical detoxification, inpatient or residential treatment, standard or intensive outpatient programs, and partial hospitalization programs. Typically, 48% of nurses attempting to recover are successful, but success rates can be as high as 90% (Trinkoff et al., 2022). Impaired nurses suffer from a 40% 5-year relapse rate, with the highest rate of relapse occurring in the first year of recovery (Mumba et al., 2019). Risk factors for relapse include spirituality and religiosity, mental illness, receiving education in the United States, and having a criminal background (Mumba et al., 2019). Alcohol is associated with a 1.7 times higher risk of relapse (Mumba et al., 2019). Treatment of substance use disorder is effective, and professional monitoring programs are often implemented as an alternative to discipline resulting in high recovery rates and return to practice (Strobbe & Crowley, 2017).

A 2017 survey showed that 7.2% of those over twelve had a SUD over the last year, with 5.4% suffering from alcohol use disorder and 2.8% with illicit drug use disorder (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Risk factors for substance use disorder include sleep difficulties, low motivation, co-morbid mental health diagnosis, history of treatment failures, poor social support, and high-stress levels (McKay, 2020).

According to the Florida Nurse Practice Act (NPA), some actions surrounding drug and alcohol use are grounds for denying a license or disciplinary actions (2021 Florida Statutes, 2021). These activities include:

  • Sale, distribution, or possession of a controlled substance.
  • Nurses cannot 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 mental or physical condition. Probable cause must exist to believe that the nurse cannot practice nursing due to the impairment. The suspected impaired nurse has to submit a mental or physical examination to a physician, and the circuit court can enforce this after a petition is filed. The accused nurse is allowed to show they can resume competent nursing practice at reasonable intervals.
  • The board should not reinstate a nurse's license who the board had 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 with their problems. The impaired nurse may be difficult to detect because they often are very careful to avoid being caught. When signs or symptoms are noticeable, it has often been going on for an extended period.

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. The willingness of the nurse to stick with the program and admit a problem are the strongest predictors of success (Toney-Butler & Siela, 2022). Often, nurses resist substance abuse treatment; and only enter a program with the encouragement of family, friends, peers, management, or 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
  • Multiple 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 reports 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
  • The discrepancy between the narcotic record and patient record
  • Altered orders
  • Unexplained need for money
  • Dishonesty
  • Increased narcotic sign-outs

Physical signs that should increase the suspicion of impairment include:

  • Slurred speech
  • Watery eyes
  • Constricted or dilated pupils
  • Shakiness/tremors
  • Unsteady gait
  • Sleepiness
  • Frequent runny nose
  • Sweating
  • Fatigue
  • Diminished alertness
  • Weight gain or loss
  • Change in appearance
  • Frequent use of gum, mints, or mouthwash
  • Frequent nausea, vomiting, or diarrhea

Certain behaviors 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)
  • Lying
  • Denial
  • Insomnia
  • Isolation
  • Defensiveness
  • Poor judgment
  • Frequent pain complaints
  • Hypoactivity or hyperactivity
  • Frequent accidents

Employer Initiatives to Promote Safety and Provide Assistance

Substance abuse contributes to missing work, injuries, reduced productivity, liability, societal harm, personal harm, and increased health care costs. It is beneficial for the employee and the employer to assist their workers in managing alcohol and substance abuse (International Employee Assistance Professional Association, n.d. & IPN, n.d.). Employers should implement strategies to promote safety and provide assistance. Guidelines should be developed to promote safety for nurses and their patients and offer help to nurses who suffer from substance abuse or other conditions that lead to impairment.

Policies should include a drug-free workplace and have 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 (SAMHSA, 2021). 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 conditions that lead to impairment.

Nurses lack education regarding the addiction process, identifying those with addiction, and implementing effective interventions. Nurses must receive education about substance use disorders, and with proper programming, employers can significantly improve the nurse's knowledge and attitude toward substance abuse. The workplace has the 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 in impaired workers and get them the help they need.

Employers may influence employees to get help for impairment. Many employers have employee assistance programs (EAP) and educational programs to help prevent and treat drug or alcohol problems. These programs may include health promotion, education, and referral to alcohol and other drug abuse treatment programs. These programs look to identify issues quickly 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 (Webster, 2022; Toney-Butler & Siela, 2022). The primary goal of an EAP is to help employees maintain their job and career.

Employers can mandate treatment for impairment, including education, referral to treatment centers, or health promotion. Treatment is in the employer's best interest because it is easier to retain a nurse than train a new hire. Training comes in education regarding the dangers of drugs and alcohol, stress management, coping skills, and identification of impaired co-workers (Toney-Butler & Siela, 2022).

While it is not illegal to drink alcohol, drinking off the job can affect job performance. For example, binge drinking may lead to hangovers the next day, compromising work performance. Employers have a reason to attempt to modify employee drinking, which may positively affect work performance. Hangovers increase the risk of bad judgment injuries, impair motor or cognitive function, and reduce work productivity.

Addressing off-the-job drinking is often done through alcohol education programs at work through EAP or another health promotion program to encourage behavioral change. Having programs available may encourage impaired patients to self-refer to treatment. Alcohol education programs may 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.

Employers often put on health promotion programs to help motivate their employees to change behaviors. Drinking and drug use can affect health; teaching employees about healthy alternatives have the potential to change behaviors. For example, engaging in exercise, adopting 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 (Toney-Butler & Siela, 2022). At times, nurses abuse substances because of work-related stress. Common work stressors leading to substance abuse include bullying, anxiety, a traumatic clinical incident, and workloads (Pezaro et al., 2021). The employer is responsible for determining if risk factors are present within the work environment and attempting 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 managing it in primary care. Preventative efforts can reduce substance use in both the worksite and the primary care setting. 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.

Employers may resist intervention in prevention programs for multiple reasons, including:

  • 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 assists substance abuse programs within companies. Over 97% of companies with more than 5,000 employees have EAP; 80% of companies with 1,001 - 5,000 employees have EAP; and 75% of companies with 251 - 1,000 employees have EAP (International Employee Assistance Professional, n.d.). EAP is 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 assessments or short-term counseling and referrals to an outside provider for follow-up treatment.

Employees may not get involved in EAP for a variety of reasons. Employees often fear breaks in confidentiality, even though that is a false assumption. 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. 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 (Office of Personnel Management, n.d.). When looking at EAP outcomes, most studies suggest that they provide positive economic benefits and improved work and clinical outcomes (Song & Baicker, 2019). Some workplaces more strongly promote EAP than others.

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 (Williams, 2017).

Other Initiatives to Offer Treatment for the Impaired Nurse

Many options are available to help the impaired nurse. Many State Nurses Associations have peer assistance programs to assist impaired nurses in getting referrals to counseling. In addition, many State Boards of Nursing have alternatives to discipline for the impaired nurse, including a peer assistance program with monitoring and support of the nurse to get them back to practicing nursing safely.

In Florida, according to Rule 64B31-10.001, an approved impaired practitioner program (IPP) 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 (Florida Administrative Code, 2022). In addition, they monitor the development of the impaired practitioner, and no medical services are provided.

The program must have a multidisciplinary team that typically manages patients in intensive outpatient or partial hospitalization settings. The IPP approves treatment providers and must be a state-licensed or nationally certified provider with experience managing the particular type of impairment affecting the nurse (Florida Administrative Code, 2022).

In addition to EAP programs, other organizations offer treatment for the impaired nurse. Two approved impaired practitioner programs in Florida are the Intervention Project for Nurses (IPN) and Professionals Resource Network (PRN). The IPN (n.d.) is a Florida-based IPP under contract with the Florida Department of Health. The program offers education, support, and monitoring for health care workers with substance use disorders. Employers often refer impaired nurses to the IPN.

When a nurse enters the IPN, an intake consultation is done, including an evaluation with recommended interventions. After the nurse is fully assessed, the nurse is referred to treatment, and at the end of treatment, a 2-to-5-year monitoring period ensues. The IPN does not treat patients but refers patients to treatment programs. The program involves the nurse signing an advocacy contract and requires the nurse to go through monitoring, including drug testing, meetings, and support groups. These programs assist the nurse in getting back their license and going back to safe practice. The nurse goes back to work when the program is complete, often with restrictions.

What to do if a Nurse Suspects Another Nurse is Abusing?

The American Nurses Association (ANA) encourages nurses to have pharmacological education about prescribed drugs' abuse, misuse, and addiction (ANA, n.d.). Armed with this education, nurses must be on the lookout for impairment. Many nurses fear reporting a colleague because they worry about retaliation. Nonetheless, a licensed health care provider must ensure all patients get safe and effective care. 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 patients. Nurses should be familiar with the organization's policy for employee substance abuse and any organization's assistance programs.

A fellow nurse should not enable another health care worker to continue to abuse substances. Enabling occurs when the substance-abusing nurse's poor performance is ignored, excuses are accepted, or the supervisor making assignments gives the impaired individual an easy patient assignment. In Florida, a nurse suspected of maintaining an impaired practice may be reported to the Florida Department of Health or an IPP by any person, and any licensed nurse is a mandatory reporter (Florida Board of Nursing, n.d.).

While the ANA is not in favor of random drug tests for nurses, if there is concern that drugs or alcohol affect work performance, it believes that testing is appropriate (ANA, n.d.-b). The ANA does not oppose controlled substances, but it is against the misuse of controlled substances.

Steps to Make a Report or Referral

It is not helpful to make excuses or cover for an impaired nurse, and it will potentially harm the nurse and their patients. The nurse should accept the consequences of their behaviors and actions. Any impaired nurse should be reported immediately to prevent adverse effects on the nurse, co-workers, or patients. Reporting a colleague can be a positive step to protecting patients and supporting their colleagues to enter into treatment programs.

Nurses must 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 lose their job or be 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 Florida, any person who suspects a nurse is impaired must report the nurse to the IPN, PRN, or the Florida Department of Health. To make a referral - call the IPN at 1-800-840-2720 or the PRN at 1-800-888-8776.

The IPN and PRN are meant to enhance public health and improve safety by offering an opportunity for quick intervention/close monitoring and support for nurses whose practice is weakened from the use, misuse, or abuse of alcohol or drugs or a mental/physical condition (2021 Florida Statutes, 2021). A nurse who cannot practice safely due to impairment violates the Florida Nurse Practice Act. The IPN and PRN offer a program for impaired nurses to be rehabilitated in a non-punitive and confidential method. The goal is to keep nurses practicing instead of losing their licenses. The programs enable early intervention to expedite enrollment into a recovery program. The nurse immediately stops practicing and does not return to practice until the IPN or PRN assures that they are safe to return to practice. It offers a cost-effective method for the disciplinary process.

Before 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 impaired nurses increased, other options were sought to help nurses back to work while maintaining patient safety (IPN, n.d.).

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 (2021 Florida Statutes, 2021) states, "Failing to report to the department any person who the licensee knows violates 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 professional's consultant." The situation 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 the protection of the public. They allow the impaired nurse to be recognized earlier and quicker implementation of interventions. 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. The IPN also evaluates the nurse in a comprehensive, standardized method and suggests approved providers and programs that offer treatment. The IPN also monitors the nurse and involves the employer in rehabilitation. The IPN program will more quickly identify a potential relapse and have the potential to offer intervention before severe negative consequences occur (Smith, 2017).

A referral is initiated with a call, followed by an intake evaluation. The suspected impaired nurse is offered interventions. The nurse can agree to the interventions or not agree. If the nurse does not agree to the interventions or does not make any progress, they will be reported to the Department of Health. If the two parties agree and the nurse makes treatment progress, the IPN will continue to monitor the nurse for 2-5 years (Smith, 2017).

The IPN offers multiple benefits, including (IPN, n.d.):

  • Implementation of an IPN contract
  • Evaluations on progress
  • Suitable referrals
  • Random urine drug screens
  • Recovery support
  • Monitoring
  • 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, 2017; Toney-Butler & Siela, 2022). Also, the IPN determines when the nurse can return to practice, which typically entails completed treatment and a signed advocacy contract. The nurse is engaged in the continuing treatment principles, such as involvement in a support group. In addition, the nurse must agree to random urine drug screens and any practice restrictions 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.

The program monitors workplace performance to provide feedback. Satisfactory progress is determined when the nurse has good monitoring reports, negative drug screens are compliant with the individualized advocacy contract, and regularly attends monitoring or support groups (Smith, 2017; Toney-Butler & Siela, 2022). Upon successful completion of the program, the record is sealed. 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 (IPN, n.d.).

The IPN does not provide the evaluation or treatment but will offer referrals to professionals to help with addiction. Referral sources from the IPN include psychiatrists, addiction specialists, or other healthcare providers in a region close to where the nurse lives. It does not cost money to participate in the IPN. Still, the nurse pays for the evaluation and treatment from the specialists and pays for laboratory evaluations and random drug tests (IPN, n.d.).

What must Nurses Do?

Nurses should know how to document concerns and recognize essential steps in making a report or referral to an IPP or the Department of Health. Nurses should:

  1. Educate themselves on signs of impairment
  2. Observe job performance
  3. Look for patterns in co-workers
  4. Learn how to document
    1. Include:
      1. date
      2. time
      3. any objective data
      4. and any witnesses
  5. Know when to discuss concerns with a supervisor
  6. Discuss with the impaired nurse how the impairment affects job performance
  7. If active impairment is present, question the nurse along with a colleague – refer to an IPP or the Board of Health; always intervene with a colleague
  8. If a nurse is impaired at work, it is essential to provide transportation home for that nurse

Planning an intervention is the first step in getting an impaired nurse's help. First, document behaviors suggestive of impairment. 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. Ideally, the intervention should occur with a nurse manager and other witnesses. The impaired nurse will often deny their impairment.

Unaddressed issues lead to problems and have the potential to be buried, and impairment will increase as others will cover and hide the co-worker's impairment. Impairment not addressed quickly places patients at risk.

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. During the previous three weeks, her appearance has gone from neat and clean to wearing dirty outfits, and her physical appearance has deteriorated. When her co-workers work with her, they notice that she often seems dazed.

Co-workers considered her unkempt appearance and her behaviors secondary to stress from working full time on the 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, leading to a referral to a treatment provider. She sees this treatment provider, goes through counseling sessions for one month, and 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 submit to 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 provides 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 correctional officers. He will often go 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 deteriorating, and he has made multiple documentation errors. He also always volunteers to do a segregation pill pass, which is an opportunity for him to 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 and has lost about 15 pounds over the last three months.

One of his co-worker’s suspects that he is using drugs and fills out a form to refer him to the IPN. The IPN does 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 implemented an investigation and determined that he is abusing alcohol, but he has been stealing tramadol and snorting it to get 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 against him.

Conclusion

Impairment is a significant problem and may affect up to 19% of nurses. It can affect the nurse's health and may adversely affect patient care. Nurses are often the first to pick up on another healthcare worker's impairment. Therefore, it is essential to be aware of the signs and symptoms of impairment.

Many resources are available to help nurses with impairment. Worksites have programs, such as the employee assistance program. In Florida, the nurse must report any impaired nurse to an alternative discipline program or the Department of Health. Alternative to discipline programs help nurses 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 are impaired.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
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Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

Reference

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