Substance Use Disorder 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 ten to fifteen 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:
- 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?
Absence & Tardiness
- Forgets how to complete simple tasks or makes mistakes (memory/concentration)
- Makes inaccurate judgments regarding patient care (judgment)
- Exhibits confusion (e.g., about directions or instructions)
- Unable to accurately communicate specific patient information with staff and/or patients
- Inaccurate or incomplete patient care documentation
- Inability to complete assigned tasks that others do adequately
- Consistent inability to improve performance or conduct even with training or counseling
- Exhibits aggression or hostility towards patients and/or coworkers
- Responds defensively or aggressively when provided performance feedback
- Inappropriate sharing of personal information with patients
- Communicates with flat affect in tone of voice
- Avoids eye contact
- Alcohol-like odor on breath
- Irregular breathing pattern (e.g., labored, shallow)
- Stumbles/staggers while walking (gait/balance)
- Changes in speech pattern (e.g., slurred, fast, slow)
- Fumbles/drops equipment (manual coordination)
- Pupils dilated/constricted
- Perspiration that appears excessive for environmental conditions
- Jerky body movements
- Reports difficulty sleeping
- Nodding out or sleeping on duty
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, 2015, 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 Substance Use Disorder 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.
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.
- 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
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.
Substance Use Disorder 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 Substance Use Disorder". 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.