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Recognizing Impairment in the Workplace Nursing CE Course

2.0 ANCC Contact Hours

About this course:

The purpose of this activity is to elucidate for nurses the challenging yet crucial issue of how best to identify and then respond to interactions with potentially impaired coworkers in the workplace. The evidence regarding the indicators, diagnosis, reporting responsibilities, investigation, treatment, and return-to-work process for impaired health care workers is discussed in order to both educate and decrease the stigma often found clouding this critical issue.

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Recognizing Impairment in the Workplace

The purpose of this nursing activity is to outline the challenging yet crucial issue of how to identify and respond to interactions with potentially impaired coworkers in the workplace. The evidence regarding the indicators, diagnosis, reporting responsibilities, investigation, treatment, and return-to-work process for impaired health care workers is discussed to promote education and decrease the stigma associated with this critical issue.

After this activity, the nurse should be prepared to:

  • recognize the statistics regarding substance use disorder (SUD) in the United States and among health care providers specifically
  • discuss the identified risk factors and effective methods for preventing SUD
  • highlight the indicators of SUD and drug diversion that a health care provider should be watchful for in the workplace
  • clarify the professional, ethical, and personal responsibilities of a nurse with concerns regarding the potential impairment of a coworker
  • briefly review the investigation and intervention steps that should occur when substance abuse is suspected in a health care provider
  • describe the diagnostic criteria and the treatment options available to health care providers diagnosed with SUD, including alternative-to-discipline programs (ATDs or ADPs), residential programs, and outpatient programs
  • discuss the return-to-work procedures for health care providers diagnosed with SUD

The National Institute on Drug Abuse (NIDA, 2018) defines tolerance to medication as the gradual need over time for an increased dose of a particular substance to obtain a similar effect. The development of tolerance varies significantly based on the individual and medication due to the brain’s ability to adapt to its environment physically. This phenomenon is not limited to pain medication or illicit drugs but also occurs in other specialties and circumstances. Physical dependence is the physiological adaptation to a medication that develops with consistent and regular use, which contributes to addiction. The medication becomes necessary for normal homeostasis and functioning. Physical dependence typically correlates with opposing symptoms of withdrawal if the medication is no longer used. Misuse of prescription drugs is the ingestion or utilization of these medications in a manner, at a dose, or by an individual outside of the prescribed context. This includes taking another person's medication or using pain medication to induce feelings of euphoria. The medical terms of substance abuse and substance dependence have been replaced in recent years by substance use disorder (SUD). This may refer to an individual who has become addicted to nicotine, alcohol, prescription medications, or illicit drugs. Addiction involves a combination of physical dependence and compulsive drug-seeking behaviors despite significant negative repercussions (NIDA, 2018). The Emergency Nurses Association and the International Nurses Society on Addictions (ENA & IntNSA, 2016) clarify that addiction is a primary, chronic disease affecting the reward, motivation, memory, and related brain circuitry that leads to characteristic biological, psychological, social, and spiritual manifestations.

Substance Use Disorder in the United States

The physiologic changes that affect individuals who abuse substances vary but may include a brain response (a temporary increase in dopamine), increased workload on the heart, acute kidney injury that may progress to chronic kidney disease with prolonged abuse, a decrease in the liver’s blood supply related to scar tissue, and increased risks for integumentary complications such as rashes, sores, ulcers, extravasations, and infection (Lockhart & Davis, 2017).

The Substance Abuse and Mental Health Services Administration (SAMHSA, 2019) conducts the National Survey on Drug Use and Health (NSDUH) regarding substance use in the United Stateswhich was last performed in 2018. This survey includes self-reported data on over 67,700 noninstitutionalized Americans over the age of 11 and targets all 50 states and the District of Columbia. It does not include data on long-term facility residents, incarcerated individuals, or homeless individuals not currently residing in a homeless shelter. SAMHSA estimates that 139.8 million Americans used alcohol in the last month, including over 2 million adolescents between the ages of 12 and 17. The latter number has decreased since 2002. Of those Americans who report alcohol use, 67 million report binge drinking and over 16 million report heavy drinking. Prescription pain reliever misuse in the past year was reported by 3.6% of respondents (a decrease from the 2015 and 2017 survey results), or nearly 10 million Americans. Sixty-three percent of these users report abusing prescription pain medication to relieve pain, and 51% obtained the medication from a relative or friend. The estimated usage in the last month of cocaine; prescription sedatives, tranquilizers, or other central nervous system (CNS) depressants; prescription stimulants; hallucinogens; methamphetamine (meth); and inhalants is provided in Table 1 (SAMHSA, 2019).

Of the 10 million Americans who reported opioid misuse in the 2018 NSDUH (SAMHSA, 2019), over half (51.3%) obtained the opioids they misused from a family member or friend. Of these, the vast majority (75%) were given away, 19% were purchased, and 6% were stolen from a friend or family member (Liu, 2020; SAMHSA, 2019). Despite the reduction in the prevalence of opioid use disorder (OUD), the morbidity and mortality related to opioid misuse remain high. Roughly 100 US residents die daily from opioid overdose (Liu, 2020). According to the Centers for Disease Control and Prevention (CDC, 2020), almost 450,000 Americans died due to opioid overdose from 1999-2018. These deaths have come in three distinct waves in that period of time. The first wave of overdose deaths occurred in the 1990s and was due to an increase in the prescribing of opioids within the medical community (CDC, 2020). This timing appears to correlate with a national initiative to better identify and manage pain as the “5th vital sign”. An article by Dr. Mitchell Max published in 1990 in the Annals of Internal Medicine, followed by a presidential address to the American pain Society by Dr. James Campbell, started a national movement to assess and consider pain more seriously in patients. This prompted new standards published by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) in 2000 to improve the management of pain in our patients. This first increase in deaths due to OUD is now considered an adverse effect of the increased focus and new standards (Baker, 2017; Spiegel, 2019). The second wave began in 2010 and was largely due to an increase in heroin use, an illicit opioid synthesized from morphine. The third and final wave came just 3 years later, beginning in 2013, and was comprised primarily of deaths related to synthetic opioids such as fentanyl (CDC, 2020).

SUD in Health Care Workers

The American Nurses Association (ANA) first included language regarding impaired practice in their Code of Ethics in 2001 (Monroe et al., 2011). In general, the prevalence rate of SUD amongst health care workers (HCWs) mirrors that of the general population, which is roughly 8 to 13% (Merlo et al., 2019). HCWs have an increased risk of OUD due to frequent access to these medications at work (Butler Center for Research, 2015; Rhodes, 2018). The ENA and IntNSA

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(2016) define impaired practice as a decreased level of competence evidenced by changes in work habits, job performance, appearance, or other erratic or concerning behaviors. The ANA estimates that roughly 10 to 15% of the nursing workforce is currently either impaired or in recovery from SUD. In fact, this is such a priority within the medical (and nursing) communities that states such as Florida have begun requiring mandatory education regarding the risks of SUD within HCWs to help medical professionals accurately identify and treat those with the condition (Lockhart & Davis, 2017). 

The Butler Center for Research (2015) at the Betty Ford Organization corroborates findings that the rate of SUDs in HCWs aligns with the rate within the general population of the United States; this starkly contrasts the decreased rates of smoking and increased rates of consistent exercise within the HCW community. Their findings indicate that 10 to 15% of HCWs will misuse substances during their lifetime, and as many as one-third of disciplinary actions against nurses are substance-related (Butler Center for Research, 2015). Up to 100,000 HCWs experience SUD per year, but this rate has decreased in the last decade among the general population and HCWs. As much as 4.4% of HCWs report heavy alcohol consumption, and 5.5% struggle with illicit drug use (Henson, 2020). Estimates of the prevalence of SUD in nurses extend as high as 20% (Monroe & Kenaga, 2011). 

Risk Factors for SUD

The risk factors for SUD in HCWs can be categorized as either general or group-specific. The general risk factors for SUD apply universally. They include a genetic or molecular predisposition, a family history of SUD, a personal history of substance use, a comorbid psychiatric condition such as depression or anxiety, and the early first use of tobacco or alcohol (Butler Center for Research, 2015; ENA & IntNSA, 2016; Lockhart & Davis, 2017). The SAMHSA (2016) also found an increased risk for SUD among individuals with a history of stress early in life due to poverty, abuse, or neglect. In adolescents and young adults, peer-group pressure is a well-documented risk factor for substance use (Lockhart & Davis, 2017). Group-specific risk factors apply only to HCWs and include:

  • increased access to narcotics, sedatives, and other commonly abused substances;
  • increased work-related stress and multiple responsibilities;
  • increased exposure to illness, death, and trauma;
  • sleep deprivation due to shift work;
  • personality traits common to HCWs, such as independence, resiliency, self-reliance, and perseverance;
  • knowledge of pharmacology and pharmacokinetics; and
  • a sense of perceived invulnerability (Butler Center for Research, 2015; ENA & IntNSA, 2016; Lockhart & Davis, 2017; Merlo et al., 2019).

According to Ervin (2015), specific risk factors for SUD in nurses include a belief that substance use aids with coping and a relative lack of formal education related to SUD. HCWs who abuse substances often report doing so to relieve stress, treat pain or depression, or increase their work performance (US Drug Enforcement Administration [DEA], n.d.; Henson, 2020). 

Prevention of SUD

To prevent SUD, the CDC published guidelines for the safe and responsible prescription and administration of controlled substances for HCWs. The CDC’s Guidelines for Prescribing Opioids for Chronic Pain identify strategies that limit the risk of opioid misuse. These guidelines aim to educate prescribers and other HCWs on strategies to reduce the risk of SUD among their patients or their patients’ friends and family. Many of these elements can be self-applied to prevent SUD in HCWs. The guidelines review various types of nonpharmacological pain management strategies including physical (physical therapy and mobilization), direct (acupuncture and transcutaneous nerve stimulation), and indirect (music therapy and aromatherapy) methods. Prior to the prescription or administration of a controlled substance, patients must be educated regarding the risks of dependence, addiction, and SUD. If the patient agrees to proceed with treatment despite these risks, they should be educated regarding the safe storage (locked medication cabinet) and disposal (local and national drug take-back programs) of controlled substances. They should be counseled on the potential risks of sharing medications with family and friends, such as causing physical dependence, overdose, and medication withdrawal symptoms, as well as the risk of progression to illicit drug (heroin) use (Liu, 2020; NIDA, 2018). 

The SAMHSA (2016) identifies three general categories of evidence-based prevention strategies for SUD. For the general public, universal prevention strategies can increase the protective factors and reduce the risk factors for SUD amongst participants. These programs tend to have the biggest impact due to a large number of targeted individuals. Examples of universal prevention programs or policies include establishing or increasing the minimum legal drinking age and national school-based programs. Selective prevention strategies apply to a subgroup of individuals who are at an increased risk of developing SUD; this allows these programs to focus their efforts and resources on a smaller group of individuals but simultaneously decreases their reach. Finally, indicated prevention programs target individuals who are already using potentially addictive substances but have not yet developed an addiction or SUD. Team Awareness and Team Resilience are examples of prevention programs for adults that have been successful for workplace or clinic-based SUD prevention efforts and could be implemented or piloted by health care organizations (SAMHSA, 2016). 

While the CDC supports extensive patient education prior to prescribing controlled substances as a prevention method for misuse and abuse, many experts also advocate for an increase in education for HCWs. They point toward the potential efficacy of improved curriculum at the student level, as well as extensive education for new employees during orientation programs regarding the risk factors, indications, and potential complications of SUD (Ervin, 2015; Monroe & Kenaga, 2011). Employee assistance programs should be established by health care organizations as an anonymous and low- or no-cost early intervention option for at-risk employees struggling with mental health or substance misuse issues. At an individual level, nurses should be aware of self-care strategies to prevent SUD by maintaining healthy coping skills, a regular exercise regimen, enjoyable hobbies, and strong relationships with friends and family outside of the workplace (Lockhart & Davis, 2017).

Indications of SUD

Compared to the general population, SUD in HCWs is under-evaluated, underdiagnosed, and undertreated. This likely results from several factors, especially a lack of peer and self-reporting due to the fear of legal, professional, social, and financial consequences of SUD diagnosis (Butler Center for Research, 2015). Although nurses in the United States are required to identify and report indications that suggest substance abuse in coworkers, many do not report due to fear of retribution or punishment, or fear of causing professional damage to their colleagues. Research is limited on this issue, but the odds of a nurse not reporting a colleague for concerns of SUD or impairment are 5 to 1. Further, many nurses choose not to self-report due to fear of termination (DEA, n.d.; Monroe & Kenaga, 2011). HCWs also note that guilt, shame, and fear of tarnishing their professional reputation contribute to their decision not to self-report (Lockhart & Davis, 2017). Practicing under the influence of substances increases the risk of malpractice, incorrect diagnosis, and prescribing errors (Henson, 2020). Education on SUD for HCWs should clearly outline the advantages of reporting concerns versus the potential consequences. Ultimately, impairment in HCWs places patients at risk of harm. There is also a risk of damage to the HCW’s and health care organization’s reputation, as well as the reputation of the nursing profession and the medical field (Dunn, 2005). Enhanced participation in scholarly forums on addiction by all HCWs will improve the collective understanding of SUD as a treatable disease and not a moral failing or personal weakness (Monroe & Kenaga, 2011).

Increasing awareness of the signs and symptoms of addiction will help nurses identify coworkers who may be struggling with addiction. The signs and symptoms of impairment or addiction may include:

  • a lack of energy or motivation
  • drowsiness
  • changes in weight, eating habits, or bathroom habits
  • conjunctival injection (red or bloodshot eyes), glassy eyes, or pupillary changes
  • sudden change in appearance (lack of interest in clothes, grooming)
  • changes in behavior (acting inappropriately, sudden insistence on privacy, being secretive or dishonest, different friends, anxiety, irritability, mood swings, poor interpersonal relationships, social isolation)
  • changes in mental functioning with loss of memory, confusion, and poor decision making
  • a need to use the substance regularly
  • an obsession with protecting or maintaining a steady supply of the substance
  • financial issues (spending money to obtain the substance without regard for its availability, requests for money without an explanation, reports of missing cash or valuable personal items from those around the user)
  • a decrease in performance at work, including poor reliability regarding deadlines, missing meetings, and an increase in careless mistakes
  • doing immoral, illegal, or unethical things to obtain the substance
  • engaging in high-risk behavior while under the influence of the substance, such as driving
  • increased absenteeism, tardiness, or frequent lengthy breaks
  • requests to work shifts with decreased supervision (night shift)
  • a scent of alcohol or the regular use of gum, mints, or mouthwash to reduce the smell of alcohol 
  • highly variable periods of productivity (hyperactivity or hypoactivity)
  • wearing seasonally inappropriate clothing (e.g., long sleeves in hot weather)
  • consistent complaints about poor behavior or attitude from colleagues and patients
  • slurred speech, tremors, excessive perspiration, or unsteady gait
  • frequent runny nose
  • frequent nausea, vomiting, or diarrhea (DEA, n.d.; Lockhart & Davis, 2017; Mayo Clinic, 2017; Rhodes, 2018).

In addition to the list above, indications of drug diversion within a health care setting may include: 

  • discrepancies in medication reconciliation records
  • patients reporting that medications brought from home are missing 
  • changes in verbal or telephone orders
  • poor documentation with illegible and incomplete portions or worsening handwriting
  • patients consistently reporting poor pain control or missing doses of controlled substances
  • spending long periods near the medication dispensers (overtime or volunteering)
  • increased wastage of controlled substances, broken vials, or a lack of documented witnesses for controlled substance administration in the medication administration record (MAR)
  • inappropriate or large narcotic prescriptions (for prescribers)
  • insisting on personal administration of controlled substances to patients or offering to provide PRN controlled substances to patients for other nurses
  • significantly more administration of PRN controlled substances by a particular nurse compared to other nurses on the same unit
  • inconsistent documentation (e.g., a dose of medication documented as administered when the patient was not on the clinical unit or did not have a corresponding prescription/order)
  • excessive spending
  • legal difficulties (DEA, n.d.; Lockhart & Davis, 2017; Merlo et al., 2019)

The ANA (2015) Code of Ethics specifies within Provision 3 that a nurse “promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). Well-intentioned HCWs often are unsure how to handle a situation in which a colleague may be impaired or diverting controlled substances. Concerned nurses should keep detailed records regarding behaviors or events that indicate a potential issue, including the time, date, exactly what occurred, and any bystanders who could serve as potential witnesses. Many states allow for anonymous reporting to the state alternative-to-discipline program (ATD or ADP; Butler Center for Research, 2015; Lockhart & Davis, 2017; Merlo et al., 2019). A method for confidentially reporting concerns is paramount for the prevention and adequate treatment of HCWs with SUD (Monroe & Kenaga, 2011). If possible, the concerned colleague should approach their impaired coworker directly and supportively encourage them to seek help and treatment for their condition (ANA, 2015; DEA, n.d.; Lockhart & Davis, 2017; Rhodes, 2018). If the subject is unwilling to admit that they have a problem and seek treatment, and suspicions have been confirmed to a satisfactory degree, the colleague should discuss their concerns with the impaired coworker’s manager or supervisor (ANA, 2015; DEA, n.d.; Lockhart & Davis, 2017; Merlo et al., 2019). Alternately, concerned individuals can contact local police, organizational security, or the DEA if there is suspicion of diverted or stolen controlled substances (DEA, n.d.). Many health care organizations have established clear policies and procedures regarding how these concerns should be reported and subsequently investigated. A detailed record of recent events will promote the smooth functioning of this system. In addition to establishing how and to whom concerns regarding substance misuse should be reported, institutional policies should also clearly establish how and when pre-employment and probable cause toxicology screens (drug testing) should occur (Lockhart & Davis, 2017). It bears mentioning that inadequate staffing levels, increased patient loads, and long shifts may cause behavioral symptoms that mimic indicators of SUD, and these potential explanations should be considered and ruled out during the investigation (Brent, 2019b). 

If an intervention occurs, concerns should be communicated to the subject in an objective and detailed manner with empathy and concern while avoiding blame, accusations, or arguments. Interventions should be led by a professional who is familiar with the subject’s role but is not a friend, employer, or close colleague if possible. The intervention should include an immediate plan of action with consequences that are clearly outlined if the plan is deviated from or declined. The subject may react to the intervention with anger, threats of legal action, and resistant or aggressive behavior (Merlo et al., 2019). Interventions should be confidential and typically include the subject’s family member(s) and direct supervisor. Experts suggest that mock interventions may assist health care organizations with intervention by reducing fear and discomfort. ATD experts should be invited to speak with organizational leaders for additional information and enhanced comfort if hesitation is encountered from the institutional level (Monroe & Kenaga, 2011).

Nurses should be aware of both the institutional policies and procedures related to reporting concerns of SUD in colleagues as well as any related statutes within their state. For example, nurses in Florida can be denied a professional license and subject to disciplinary action for the following: 

(j) Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the [Florida Department of Health] shall have, upon a finding of the State Surgeon General or the State Surgeon General’s designee that probable cause exists to believe that the nurse is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a nurse to submit to a mental or physical examination by physicians designated by the department. If the nurse refuses to comply with such order, the department’s order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the nurse resides or does business. The nurse against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in section 51.011. A nurse affected by this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.

(k) Failing to report to the department any person who the nurse knows is in violation of this part or of the rules of the department or the board. However, a person who the licensee knows is unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material, or as a result of a mental or physical condition, may be reported to a consultant operating an impaired practitioner program as described in section 456.076 rather than to the department (Florida Legislature, n.d.b, para. 11 and 12).

Diagnosis of SUD

According to the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 2013), SUDs are defined as a configuration of symptoms resulting from the use of a specific substance, ranging in severity, which result in a variety of physical, social, financial, and psychological consequences. The diagnosis of SUD is clinically based on a thorough patient history. The DSM-5 lists 11 different diagnostic criteria covering four broad categories: lack of self-control (1-4), social impairment (5-7), personal risk (8 and 9), and pharmacological criteria (10 and 11). Mild SUD is diagnosed when a patient meets 2 to 3 criteria, moderate SUD is diagnosed when the patient meets 4 or 5 criteria, and severe SUD is diagnosed when 6 or more criteria are met (APA, 2013). 

Treatment of SUD in HCWs

Historically, nurses and other HCWs with SUD experienced the standard discipline mechanisms used for other practice infractions; these were facilitated by the Board of Nursing (BON) and corresponding state medical and allied health boards. These punitive policies tended to be ineffective, endangering public safety by discouraging impaired HCWs from seeking help. Professional discipline typically results in a report to the Office of the Inspector General, which can complicate or preclude the HCW’s ability to obtain future liability or health insurance coverage (Monroe & Kenaga, 2011). In the early 1980s, the ANA began recommending that state BONs develop non-punitive, early intervention programs to advocate for the rehabilitation of HCWs. These ATDs (or ADPs) offer assistance as opposed to judgment (Ervin, 2015; Monroe & Kenaga, 2011). They advocate for the protection of public safety by addressing below-standard practice, not by eliminating well-trained HCWs with a treatable illness. The ANA further stresses the importance of advocating for or obtaining via collective bargaining certain policies and actions that promote patient safety and HCW well-being. ATD programs should remain confidential and anonymous—except in instances of gross professional misconduct—to encourage willing participation by those struggling with SUD (Monroe & Kenaga, 2011).

Most states now offer ATD programs for impaired HCWs, but at this time, it is unclear if an anonymous ATD program is available in Alaska, Georgia, Nebraska, and North Dakota (National Council of State Boards of Nursing [NCSBN], n.d.). The National Organization of Alternative Programs (NOAP, n.d.) was founded in 1999 to facilitate the multidisciplinary promotion of public safety through the rehabilitation, monitoring, research education, and standardization of ATD programs. This group emphasizes fitness to practice and the retention of trained and successfully treated HCWs in active recovery. Their primary values consist of public safety, HCW retention, education, equality, and cooperation with regulatory and professional organizations (NOAP, n.d.). In most states, the HCW is required to take a temporary leave of absence from medical practice while undergoing initial treatment, usually by temporarily or conditionally suspending their license to practice in that state (Lockhart & Davis, 2017). Some states allow the nurse to continue working while in treatment. When referred to an ATD program via their employer or another party, the nurse in question should accept the settlement of entrance into the ATD program from the BON without asking for a formal hearing, as this usually ensures anonymous entry. Most BON hearings are recorded publicly, breaching anonymity, and may become adversarial and expensive. This acceptance can avoid disciplinary action, which could carry legal ramifications. It typically involves signing a contract that outlines the treatment plan, conditional license terms and conditions, and any consequences for breach of contract or premature abandonment of treatment. Eligibility for ATD programs varies by state, and some disqualify nurses if they have caused patient harm or diverted controlled substances for the purpose of selling them to others (Brent, 2019a). Experts stress the cruciality of open and forthright communication with the state BON and legal staff throughout the process (Brent, 2019b). ATD programs report a higher rate of male participants compared to the nursing workforce, and only a small portion (under 15%) of ATD participants are self-referred. Most ATD participants are referred by their employers (Ervin, 2015). State ATD programs report variable success rates of 48 to 90% (Monroe et al., 2011). The American Association of Colleges of Nursing (AACN) advocates for similar nonpunitive policies regarding impairment in nursing students (Monroe et al., 2011). 

The Joint Position Statement on Substance Abuse Among Nurses and Nursing Students (ENA & IntNSA, 2016) outlines the following four points:

  1. Health care facilities [should] provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces. 
  2. Health care facilities and schools of nursing [should] adopt alternative-to-discipline (ATD) approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and re-entry into safe, professional practice. 
  3. Drug diversion, in the context of personal use, is viewed primarily as a symptom of a serious and treatable disease and not exclusively as a crime. 
  4. Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion, and have the responsibility and means to report suspected or actual concerns (ENA & IntNSA, 2016, p. 2).

If a nurse or other HCW has an SUD and declines to participate in the ATD rehabilitation program recommended by the state BON, then the traditional discipline process should occur with removal from practice if negligence can be proven (Monroe & Kenaga, 2011).

Some states require a formal evaluation by an addiction specialist to recommend a treatment plan initially (Brent, 2019b). Treatment for SUD among HCWs or laypersons should be individualized, comprehensive, and biobehavioral. Inpatient or residential programs typically facilitate detoxification in a safe environment and offer around-the-clock support, but this option typically involves significant expense. Medications for acute withdrawal during detoxification may be utilized, especially for patients with alcohol or benzodiazepine withdrawal, such as diazepam (Valium), chlordiazepoxide (Librium), and methadone (Dolophine, which may be used for weaning patients off narcotics). Intensive outpatient or day programs are typically less costly. Either option should consist of extensive patient education (even for HCWs); ongoing individual, group, and possible family therapy; and strategies for relapse prevention. Individual psychotherapy is usually based on cognitive behavioral therapy (CBT). In a group setting, community reinforcement groups like Alcoholics Anonymous (AA) and similar 12-step programs may assist throughout recovery and prevent relapse over time. Research also supports the effectiveness of contingency management or motivational incentives, which reward participants tangibly for maintaining sobriety and abstinence (Lockhart & Davis, 2017). Professional discipline and regulatory intervention have, for the most part, been replaced by self-regulation (Monroe & Kenaga, 2011). Participants in qualitative studies have cited the importance of participating in a support group with nurses or other HCWs struggling with substance abuse. They also indicate that random drug screening and a highly structured program are extremely helpful initially (Ervin, 2015). Quantitative studies demonstrate that random drug screening is over 95% effective at assisting participants with maintaining sobriety. Treatment programs for HCWs should be more intensive and consist of a longer monitoring portion than standard SUD treatment programs (Butler Center for Research, 2015).

Barriers to recovery and sobriety maintenance include an increased problem burden (i.e., financial strain, legal ramifications, etc.), poor mental or physical health, and continued substance use (Monroe et al., 2011). Participants of ATD programs report roughly 75% lower problem burden while increasing the chances of recovery and return-to-work and decreasing the risk of relapse (Monroe & Kenaga, 2011). To alleviate some of the problem burden, the Family and Medical Leave Act (FMLA) guarantees a period of unpaid leave for those in treatment for SUD, securing their job placement temporarily. The Mental Health Parity and Addiction Equity Act ensures equivalent coverage benefits in most insurance plans for outpatient, inpatient, or emergency care related to SUD. Finally, some professional liability products have begun covering the expense of disciplinary hearings in recent years. Many states offer legal reprieve through first offender programs (FODPs), which may facilitate treatment and offer probation to avoid a criminal conviction. If a criminal conviction is in place, this may preclude the HCW from obtaining a nursing or other state license, depending on the regulations in their particular state (Brent, 2019b). State legislatures establish the guidelines by which nurses and other HCWs can obtain treatment for SUD. For example, the Florida regulation referenced above, section 456.076, establishes the Florida Impaired Practitioner Program; details can be found on the Florida state legislature’s website (Florida Legislature, n.d.a). A small section of this legislation is highlighted below, indicating eligibility for the program, some of the confidentiality terms, and conditions of legal immunity and liability:

(9)(a) Except as provided in paragraph (b), when the department receives a legally sufficient complaint alleging that a practitioner has an impairment and no complaint exists against the practitioner other than impairment, the department shall refer the practitioner to the consultant, along with all information in the department’s possession relating to the impairment. The impairment does not constitute grounds for discipline pursuant to section 456.072 or the applicable practice act if:

1. The practitioner has acknowledged the impairment;

2. The practitioner becomes a participant in an impaired practitioner program and successfully completes a participant contract under terms established by the consultant;

3. The practitioner has voluntarily withdrawn from practice or has limited the scope of his or her practice if required by the consultant;

4. The practitioner has provided to the consultant, or has authorized the consultant to obtain, all records and information relating to the impairment from any source and all other medical records of the practitioner requested by the consultant; and

5. The practitioner has authorized the consultant, in the event of the practitioner’s termination from the impaired practitioner program, to report the termination to the department and provide the department with copies of all information in the consultant’s possession relating to the practitioner.

(b) For a practitioner employed by a governmental entity who is also certified by the department pursuant to part III of chapter 401, the department may not refer the practitioner to the consultant, as described in paragraph (a), when the practitioner has already been referred by his or her employer to an employee assistance program used by the governmental entity. If the practitioner fails to satisfactorily complete the employee assistance program or his or her employment is terminated, the employer shall immediately notify the department, which shall then refer the practitioner to the consultant as provided in paragraph (a).

(10) To encourage practitioners who are or may be impaired to voluntarily self-refer to a consultant, the consultant may not provide information to the department relating to a self-referring participant if the consultant has no knowledge of a pending department investigation, complaint, or disciplinary action against the participant and if the participant is in compliance and making progress with the terms of the impaired practitioner program and contract, unless authorized by the participant.

(11) In any disciplinary action for a violation other than impairment in which a practitioner establishes the violation for which the practitioner is being prosecuted was due to or connected with impairment and further establishes the practitioner is satisfactorily progressing through or has successfully completed an impaired practitioner program pursuant to this section, such information may be considered by the board, or the department when there is no board, as a mitigating factor in determining the appropriate penalty. This subsection does not limit mitigating factors the board may consider (Florida Legislature, n.d.a, para. 30).

Roughly 9,000 nurses reenter the workforce while in recovery every year in the United States (Monroe et al., 2011). The ANA (2015) advocates for a pathway whereby nurses and other HCWs may return to work upon successful completion of their treatment program in the current version of the Code of Ethics. Most ATD programs have established standards that must be met before an HCW can return to practice, as shown in Figure 1.

Some states require a formal evaluation by an addiction specialist to release an HCW before they return to work or periodically for follow-up (Brent, 2019b). In most states, the HCW can return to work on a limited, conditional, or contingent basis initially. This period may include a limitation of hours or patient load, restrictions regarding the administration or prescription of controlled substances, random toxicology screenings, and mandatory ongoing treatment in the form of support groups, group therapy, or individual outpatient treatment. Research suggests colleagues welcome the HCW back without judgment or a need to regain trust. Knowing their peers and coworkers are truly glad to have them back on the team facilitates the HCW’s process of self-acceptance and overcoming feelings of guilt and shame (Lockhart & Davis, 2017). Many HCWs cite significant difficulty with stigma upon returning to work following treatment for SUD (Ervin, 2005). The three stages of recovery from SUD are often referred to as early sobriety (the first year), sustained recovery (1-5 years), and stable recovery (after 5 years). Maintaining a personal and social support system helps ensure an effective long-term recovery (Monroe et al., 2011). Targets of ongoing monitoring conditions are shown in Figure 2.

A nurse in recovery during active monitoring will be supervised closely by the nurse manager on the unit. The supervising nurse manager will have an ongoing opportunity to provide feedback to the BON or ATD facilitators regarding the nurse’s conduct (Monroe et al., 2011). Unfortunately, studies have shown HCWs with OUD are at increased risk of relapse in comparison with the general population. However, 81% of HCWs who complete an ATD program maintain sobriety at 5 years (Butler Center for Research, 2015). Figure 3 lists expected questions for supervising nurse managers who are working with a nurse in active recovery.

For additional information on the pathophysiology, diagnosis, and treatment of SUD, please see the NursingCE continuing education activity entitled Substance Abuse and Addiction.


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