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.
This course aims to help healthcare professionals identify and support colleagues who may be afflicted with workplace impairment.
≥92% of participants will report an increase in knowledge regarding how to access and manage the impaired healthcare professional.
Alcohol and drug use are becoming more of an issue for healthcare providers. Impairment from these substances may continue or progress if not identified, compromising the ability to care for patients safely. The risk of patient harm is higher when impaired nurses care for those in the emergency department, operating room, or intensive care unit (ICU). Because of the risk associated with impairment, employers and peers must recognize the signs and report them when identified (Edvardsen et al., 2015; Toney-Butler & Siela, 2022).
Drug and alcohol use in nursing is a significant problem; one survey showed that 18 percent of nurses demonstrate substance abuse, and 6.6 percent suffer from a substance use disorder (SUD) that could interfere with employment (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 a nursing home suffer from substance misuse (Trinkoff et al., 2022).
Another survey demonstrated that nurses in long-term care, medical-surgical units, and in-home health care have a higher risk of impairment (Mumba et al., 2019a).
Misusing prescription drugs is most common in nurses employed in assisted living, nursing homes, home health and hospice agencies, and government/military settings. Alcohol use, one of the most commonly reported abused substances, is frequently abused by healthcare professionals in government/military settings, home health, hospice, nursing homes and assisted living facilities, those working in multiple facilities, and those employed in a hospital or ambulatory care. Illicit drug abuse, less commonly abused by healthcare professionals, is often abused by those employed in hospitals, nursing homes, and those who are in multiple workplaces (Salani 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. Substance use is often a mechanism to cope with stress from the job (Trinkoff et al., 2022).
Continued abuse of substances could result in poor health for the abuser. Stimulant abuse may cause high blood pressure, chest pain, and heart attacks. Alcohol abuse can cause liver cirrhosis. Impairment may cause or exaggerate mental disorders such as anxiety and depression or even suicide. Physical risks, such as falls and fractures, are also possible (Toney-Butler & Siela, 2022).
Some impaired healthcare professionals, including nurses, can employ mechanisms to cover up their impairment. However, as substance use progresses, the ability to safely care for others decreases. Eventually, impaired nurses may start to make subtle mistakes that progress to more noticeable procedural or medication errors (Toney-Butler & Siela, 2022).
It is essential to recognize that impairment may not always be due to substance use. However, it is always our duty to report impairments, as impaired nurses may not be able to perform the required responsibilities safely, and they are a direct representation of the institution they are employed at and the profession as a whole (Toney-Butler & Siela, 2022; Cash et al., 2015).
SUDs are a complex condition with uncontrolled substance use that is often 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 desire to change and their stage of change. A complete medical evaluation may include medical and surgical history, psychiatric diseases, laboratory evaluations, and family and social issues.
In addition to the type of substance used, ascertain the use pattern, last use, frequency, 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 is associated with hepatitis and human immunodeficiency virus [HIV], and intranasal use is associated with infectious diseases 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.
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 reaches the harmful use stage, a SUD is recognized and 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 or prescription drug for non-medical reasons?" This question is 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 SUD 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, a family history of substance abuse, or stress. Stressful events commonly seen in nursing include nurse-to-patient ratios, staff shortages, shift work, elevated workloads, and mandated overtime. Nurses may also suffer from patient deaths, erratic workplaces, and being required to work outside their scope of practice (Webster, 2022).
The most common cause of workplace impairment is caused by chemical and substance use, such as with alcohol and prescription and non-prescription drugs. Often there are reasons and stressors that influence substance abuse. They can include genetic causes, such as a family history of abuse and/or neurotransmitter deficits. Employment risk factors include mental and physical fatigue from responsibilities, stressful tasks, staff shortages, toxic environments, lack of training, organization changes, and an excessive workload or extended work hours (Toney-Butler & Siela, 2022).
Personal factors contributing to an increased risk of a SUD include personal stresses, such as finances, physical illness and pain, lack of sleep, family issues, and pregnancy.
Opioid pain medications may be used initially as prescribed. Increased pain from cancer, arthritis, diabetes, or chronic diseases may occur, leading to the need for increased doses or frequencies. Psychological risk factors include low self-esteem, depression, an addictive personality, poor coping mechanisms, and decreased competence (Toney-Butler & Siela, 2022).
The consequences of abuse and impairment may be more challenging for healthcare professionals than the general population. Because nurses provide direct care to patients, they are accountable and responsible for their actions. Therefore, nurses must be aware of risk factors, including personal ones, and symptoms of substance use.
As discussed, nurses may face more risk factors compared to others. On top of that, peer pressure and poor coping increase vulnerability. Knowledge of these substances' effects and their abilities to induce calm and relaxation may entice nurses. Past histories of nurses, such as a history of alcohol and drug use, can increase the chances of abuse, especially when stressful life events occur. Trauma is a common risk factor for substance abuse. And as nurses experience traumatic events many times at work, the risks are increased; therefore, the risks must be recognized and analyzed (Chan et al., 2017; Cares et al., 2015).
Not only do SUDs contribute to patient harm, but they also increase the risk of social harm, liability and lawsuits, missed work, and an increase in healthcare costs. Because of the potential risks, colleagues and employers must be prepared to recognize and treat SUDs when they arise.
However, if none of these techniques are successful, nurses may take the substance they crave, resulting in discrepancies. Examples of discrepancies include missing narcotics or incorrect narcotic counts, medication record corrections, increased narcotic wasting, continual medication order changes, and increased patient complaints of uncontrolled pain (Barrett, 2023).
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 nurses often fear reporting their colleagues.
The International Nurses Society and the Emergency Nurses Association developed a position statement on substance abuse in nursing (Strobbe & Crowley, 2017). It includes:
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.
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., 2019b). 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 feeling 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).
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., 2019a).
According to the Florida Nurse Practice Act (NPA), some actions surrounding drug and alcohol use are grounds for denying a license or disciplinary actions (The Florida Legislature, 2021). These activities include:
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 injectable medication from a patient to use for themselves and give the patient a diluted 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, the substance abuse has often happened for an extended period (Toney-Butler & Siela, 2022).
Physical signs that should increase the suspicion of impairment include (Toney-Butler & Siela, 2022):
Five classes of drugs are frequently abused and used in drug diversion: stimulants, anabolic steroids, depressants, hallucinogens, and opioids. Fentanyl, an opioid, is the most commonly diverted drug and adds to the opioid crisis (Tanga, 2011).
When drug diversion is expected, detailed and accurate documentation is required. It should be specific, objective, and confidential, except for the appropriate personnel. Some employers have nurse educators responsible for detailing policies and procedures, including ones relating to drug diversion. It is often their job to determine flaws in the system and where a breach occurred that may have contributed to drug diversion.
After an investigation, proper actions must be taken to ensure consequences are in place and actions are taken to prevent future drug diversions. Educators and employers are obligated to ensure patient safety; further consequences are possible if educators and employers do not investigate instances of drug diversion. In fact, employers and educators could be charged with negligent supervision if they fail to report an impaired nurse that puts patient safety at risk.
A written policy should be provided to all employees upon hiring/training and be available at all times for reference. Discussions between nurses, pharmacists, educators, risk management, and all providers should occur regularly to ensure everyone is up to date on the most current information on preventing drug diversion. Also, information should be available on how to report drug diversion and the appropriate actions to take (Tanga, 2011).
Employers and nurses are ethically bound to protect patients, the community, and the profession. Colleagues, nursing leaders, and even administration are also required to prioritize patient safety, meaning that reporting an impaired nurse is necessary so that they can receive appropriate treatment and care. If impairment is suspected or confirmed, they should not be allowed to provide care as it would subject patients to harm. Employers must realize that drug diversion is often a symptom of a more significant problem, such as addiction, and must be managed carefully.
Programs exist that specifically focus on drug diversion as a symptom of addiction. Diversion programs are essential to ensure proper treatment and allow nurses to return to the profession. Alternative-to-discipline programs are in place to help impaired nurses recover and maintain employment. Most nursing boards and the American Nurses Association (ANA) support non-punitive measures. The ANA's Code of Ethics encourages and supports promoting the nurse's well-being, including through rehabilitation (Tanga, 2011).
Because drug diversion affects the nursing department and facility, employers are responsible for assisting impaired nurses through their anger and feelings of betrayal after being reported (Tanga, 2011). Servant leadership strategies may help impaired nurses through their addiction with goals of empathy, healing, awareness, foresight, community-building, and listening (Zada et al., 2022). Counseling services may assist with the impaired nurse's suffering and emotions.
All facilities should have systemwide initiatives used to prevent and detect drug diversion. Education plays a significant role in prevention and detection, so employers, employees, and colleagues should be taught to recognize symptoms and patterns associated with drug diversion. Awareness of this significant issue would help to shed light on an ongoing crisis because every facility that stores and dispenses medications is at risk for drug diversion (Tanga, 2011; Nyhus, 2021).
There are specific patterns to look for that may indicate drug diversion:
Impaired healthcare professionals may not realize that they are inducing suffering in their patients, especially if they divert substances from patients to themselves. Under-medicated patients may feel extra pain or anxiety if they are not receiving their benzodiazepines or opioids (Toney-Butler & Siela, 2022). Drug diversion has significant effects and serious implications. Prevention and detection are key.
Preventing drug diversion begins with the recognition and awareness of its potential and risks. Drug diversion and substance abuse are more common than most realize, and without the ability to recognize them, it will only continue.
Peers and coworkers may recognize drug diversion but fail to report it. Increased reporting would potentially increase awareness of this significant issue.
Preventing drug diversion is not a simple fix. It requires a multidisciplinary approach, from nurses to pharmacists. Together, changes can be made. For example, the smallest doses and different dosage forms can be provided. Pharmacists providing the most accurate doses prevent the need to return or waste anything. Employing ready-to-use doses allows for less manipulation and increased safety.
If wasting must occur, wasting when the medication is removed is the best practice. Waste receptacles should be used, as they bind the drug, decreasing the likelihood of drug diversion.
Partially used pre-filled bags and syringes, fentanyl, and expired medications are examples of items that should be wasted (Nyhus, 2021).
There are different treatment options for patients and nurses with SUD. Treatment depends on a multitude of factors, including the level of care necessary and risk factors for relapse.
IOP is convenient for patients/nurses as they can maintain normalcy, live at home, and perform daily routines. It is a flexible option for those with demanding work, school, and family schedules. However, home environments must be conducive to supporting the patient/nurse in an alcohol and drug-free environment. IOP is a viable option for those coming home after an inpatient hospitalization. If necessary, IOPs may include detox and medication management.
An IOP may not be exactly what a patient or nurse needs and a step-up in care may be required at a facility that can offer higher levels of care, such as a hospital or residential facility. Withdrawal symptoms from dependency or the process of detoxification are intense and have unpleasant symptoms, which may result in cravings or a relapse. Supervision during these crucial time stages is advised (Webster, 2023).
Medication management is often a part of IOP. Medications may be used to prevent cravings. For example, some medications create unwanted side effects if a patient consumes alcohol. The goal of these medications is to prevent relapse. Many facilities often collaborate with mental health providers to provide psychiatric services and monitoring.
Routine monitoring is standard for an IOP program, regardless of the substance being abused. Self-reporting is often used but may not be able to be relied upon. Many facilities utilize blood, urine, or saliva screening tests to ensure a patient has maintained sobriety (Webster, 2023).
Residential treatment is utilized when 24-hour supervision is necessary. It provides safe care in a structured environment where patients come to live temporarily during treatment. It is an excellent option as there is continual access to staff and peers for support. Most residential treatment facilities have therapists and behavioral health specialists to treat mental health disorders.
Examples of residential treatment include facilities where patients live and complete a program for 1-2 months or live and complete a program for six months to a year. Other residential treatment facilities include therapeutic communities or long-term sober houses (Miller, 2023).
Each individual requires a different level of service based on their needs. Patients/nurses may, at first, require a residential treatment facility but progress to only needing an IOP. Individual circumstances are reviewed and include an assessment of the following:
These factors help determine the level of care a patient/nurse needs. The American Society of Addiction Medicine (ASAM) defines five care levels: outpatient services, early interventions, intensive outpatient services, residential treatment facilities, and medically managed intensive patient services.
The least intensive type of care requires five hours of treatment weekly. Moderately intensive care may require access to 24-hour care, depending on the needs of its patients. An intense program involves counseling and treatment staff being available around the clock (Miller, 2023).
Partial hospitalization, or PHP, is a type of treatment for patients/nurses who require a higher level of care than could be provided on an outpatient basis. Sometimes it is referred to as daytime treatment. Typically, a patient receives intense and comprehensive care and monitoring during the daytime but goes home at night. Patients who are in a PHP program receive therapy, both one-on-one and in a group setting, counseling, medication management, and sobriety support. A PHP allows for easy access to higher levels of care if required (Crane, 2022).
Patients usually come to a PHP between three and five days a week, depending on their needs. Patients may spend six hours a day at a PHP.
A PHP may be used as a step-down unit for patients who previously required intense hospitalization for treatment. Typically, they should be used for patients who do not require 24-hour care but still require high support and monitoring (Crane, 2022). The individual care needs are assessed to determine which services are necessary to maintain sobriety. Typically, PHPs offer the following:
Institutional programs are used for many patients/nurses requiring a high level of care. Nurses may be mandated by their employer to complete in-person and hospitalized care. Employers may assist with education, referrals, health promotion, and treatment.
Because it is expensive to hire and train a nurse, employers usually invest in the nurses they have, meaning they may assist with the payment of institutional care or hospitalization. Paying for treatment saves the cost of hiring and training another professional (Toney-Butler & Siela, 2022).
There are many reasons that nurses may avoid treatment, some unknowingly. First, nurses may deny their condition; it is very common in those with a SUD. Denial is a psychological defense or unconscious process that prevents anxiety and discomfort. Nurses often believe they can stop using when they are ready, on their own.
Another treatment barrier involves the stigma associated with SUDs. The idea of nurses being labeled as an addict can prevent a nurse from asking for help. They may feel that discrimination and prejudice will prevent them from being looked at in the same way again (Monroe & Kenaga, 2011).
There also may be a lack of knowledge regarding the signs and symptoms of SUDs. Therefore, recognition may not be possible. Nurses may also not be aware of their options for treatment and fear discipline. It may not be worth it to them to seek treatment if it means losing their job and license. Beyond that, nurses fear facing jail time and limiting all future employment opportunities.
Nurses may be able to hide the signs and symptoms of substance abuse and addiction. Therefore, recognizing the symptoms to report may be difficult. They often become clever with their excuses for symptoms, such as stress. Once identified, colleagues and peers may be reluctant to report for a variety of reasons, including the following:
The ANA encourages nurses to have pharmacological education about prescribed drugs' abuse, misuse, and addiction (ANA, 2018a). 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 healthcare 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 policies for employee substance abuse and any of the organization's assistance programs.
A fellow nurse should not enable another healthcare 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.
Nurses must guard against behaviors that promote impairment among fellow nurses. The nurse should not ignore signs of impairment or enable 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 Florida Legislature, 2021).
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 job to report it to a supervisor. Anyone suspecting a nurse is impaired in Florida must report the nurse to the Intervention Project for Nurses (IPN), the Professionals Resource Network (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.
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 IPN offers many benefits, including the protection of the public.
A referral is initiated with a call, followed by an intake evaluation. The suspected impaired nurse is offered interventions. The nurse can agree or disagree to the interventions. 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 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, laboratory evaluations, and random drug tests (IPN, n.d.).
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 [EAPA], 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.
Employers should ensure they educate their staff on the rules and effects of alcohol and substance use. Education should also include early warning signs of substance use and addiction (Toney-Butler & Siela, 2022).
Policies should include a drug-free workplace and have all nurses fit to practice. Practices that 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 (Substance Abuse and Mental Health Services Administration [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 may lack education regarding addiction, identifying those with addiction, and implementing effective interventions. Nurses must receive education about SUDs, 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 coworkers 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 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 coworker identifies a drug or alcohol problem in another worker (Webster, 2022; Toney-Butler & Siela, 2022).
Employers can mandate treatment for impairment, including education, referral to treatment centers, or health promotion. Treatment is in the employer's best interest because retaining a nurse is easier than training a new hire. Training assists with education regarding the dangers of drugs and alcohol, stress management, coping skills, and identification of impaired coworkers (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.
Addressing off-the-job drinking is often done through alcohol education programs through EAP or another health promotion program to encourage behavioral change. Having programs available may encourage impaired nurses to self-refer to treatment. Alcohol education programs may teach workers to identify an impaired coworker. 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 their behaviors. Drinking and drug use can affect health; teaching employees about healthy alternatives have the potential to change behaviors.
Addressing alcohol and drug use in the work setting is similar to managing it in primary care. Preventative efforts can reduce substance use in 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 may not be the highest priority goal.
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 (EAPA, 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 for 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 needing 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.
Determining impairment from mental illness is a tricky task.
Many options are available to help the impaired nurse. Many state nurse associations have peer assistance programs to assist impaired nurses in getting referrals to counseling. In addition, many nursing boards 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.
The program must have a multidisciplinary team that typically manages patients in intensive outpatient or partial hospitalization settings.
In addition to EAP programs, other organizations offer treatment for the impaired nurse. 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 healthcare workers with SUDs. 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 monitoring period ensues. The IPN does not treat patients but refers patients to treatment programs.
Recovery can be supported by employers and colleagues, as they are likely to be involved with the entire process. Discussions of recovery and reentry should occur as the process develops.
Employers should also encourage and utilize personal and social support, as it helps predict recovery outcomes. Sobriety and relapse prevention are more successful when employers promote treatment programs and community support (Monroe et al., 2011).
Sobriety is not a short process and often occurs in stages. Recovery starts with remission from using substances and progresses to the enhancement of health and community inclusion. Sobriety is considered to be in the early stages in the first 12 months after remission when relapse is more common.
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:
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.
Unaddressed issues lead to problems and have the potential to be buried, and impairment will increase as others will cover and hide the coworker's impairment. Impairment not addressed quickly places patients at risk (Salani et al., 2022).
Self-care is essential in nursing and may help prevent substance use and SUDs. Because nurses spend most of their time caring for others, they may forget about their own self-care. Ensuring self-care is an aspect of daily routines is essential to prevent fatigue, burnout, and even SUDs (Salani et al., 2022).
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 coworkers work with her, they notice that she often seems dazed or sedated.
Coworkers considered her unkempt appearance and 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 coworkers said, "How could a responsible nurse and mother do that?"
One of Holly's coworkers approaches and tells her she is concerned about her behavior. 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. She is eager to get help.
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 return 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.
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 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 deteriorating, and he has made multiple documentation errors. On top of these errors, verbal and phone orders from the physician have been changed. 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. He is often gone for longer periods of time than should be expected. When he returns from his segregation pill pass, he is always in a much better mood. Recently, 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 coworkers suspects he is using drugs and fills out a form to refer him to the IPN. The IPN does consultation, 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 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 and 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.
Unfortunately, drug and alcohol use is a prevalent issue among nursing professionals. Impairment is a significant problem and may affect up to 19% of nurses. Impairment may result from SUDs. Various reasons cause the development of a SUD and include genetic, personal, and environmental factors. SUDs can be caused by a combination of these, but the work environments nurses are exposed to can significantly increase the chances of misusing substances. Long work hours, overtime, extreme stress, and trauma, such as patient deaths, are all risk factors for the development of a SUD.
The type of drug abused depends on many factors, but opioid misuse is relatively common. Nurses who work in hospice, government agencies, or who float to many worksites are at an increased risk of misusing substances.
There are different ways that nurses can obtain drugs to use. They can steal prescriptions, ask a colleague to write a prescription for them, or withhold drugs from patients. Drug diversion, taking drugs illegally to use them, can cause harm and put patients at risk. Signs and symptoms of a SUD and drug diversion include dishonesty, mood changes, frequent breaks or disappearances, fatigue, sedation, anger, and paranoia.
Impairment and SUDs 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. Reluctance to report colleagues and nurses is a challenge to treatment. Nurses may fear retaliation or truly feel bad for their nurse and friend. However, a lack of reporting is not only doing them harm but decreases patient safety.
There are many treatment options for nurses, and it depends on if the employer is involved. Employers should be invested in their nurses and assist with recovery instead of hiring and training someone else. PHPs, outpatient services, and residential programs are all available. It depends on the level of care a nurse needs, such as if detoxification or medication management is required to assist with recovery.
Many resources are available to help nurses with impairment. Worksites have programs, such as the employee assistance program. In Florida, the nurse must report impaired nurses. Alternative 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.
Reentry into the nursing field depends on the successful completion of a program, which may include weekly counseling sessions or support groups and random urine drug screens. The nurse must also feel mentally ready to return to the field. Readiness should also be determined by the employer. Ideally, the employer should be a part of the process from beginning to end, assisting the nurse with recovery efforts at all stages.
Impairment, drug diversion, and SUDs can be prevented. Employers should educate their staff on risk factors and provide training when hiring nurses and throughout the year. Access to education and information should be provided. Nurses must recognize their own risk factors and any potential biases or stigma to drugs or alcohol that may increase the chances of use. Nurses must also ensure that self-care is implemented into daily regimens. As nurses spend most of their time caring for patients, it is easy to forget about caring for oneself.
One of the most significant challenges of treatment is assisting nurses with their feelings of denial and poor coping and defense mechanisms. Colleagues must ensure empathy and compassion while maintaining accountability in a positive environment; this is a part of the ANA's code of ethics. Nurses may feel bad about reporting their colleagues and friends, but it is in the best interest of everyone involved, as our duty to patient safety comes first.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
