The Chemically Impaired Nurse

1. The Chemically Impaired Nurse Julia Apostolescu KimiMarchion Meghan Shenot

2. Addiction • What is addiction? • “The compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological systems upon withdrawal.”

3. Common drugs • Anesthesiologists often become addicted to fentanyl • Nurses often become addicted to: • Meperidine • Amphetamines (“use on your own”- without a prescription) • Opiates (“use on your own”- without a prescription) • Sedative/hypnotics (“use on your own”- without a prescription) • Tranquilizers (“use on your own”- without a prescription) • Inhalants (“use on your own”- without a prescription) • Other drugs include • Methylphenidate and amphetamines (stimulant like cocaine) • hydrocodone and oxycodone (opioid like heroin)

4. Reasons why people become addicted • The main reason why healthcare workers become addicted to drugs is because they are around medications daily and they are readily available to them • Nurses with easier workplace access reported higher rates of substance use • Nurses believe they have the ability to control and monitor their own use of drugs, due to their experience administering drugs and observing the effects on patients

5. Why people become addicted • Low levels of parental interest when he/she was growing up • Exposed to drugs during childhood • Gender (males>females) • Conduct and attention problems may lead to addiction of illicit drugs later in life

6. How people obtain drugs • The most obvious way nurses can obtain drugs is from the workplace • Some may be friends with a prescriber • Some may steal them from patients • Some people have had a prescription from previous health problems

7. Identifying if your co-worker is addicted • A co-worker may: • Continually be absent: Miss many days of work, take sick days, take long lunch hours, disappear from the unit • Have sloppy charting • Have many errors, like medication errors • Have personality changes or mood swings • May eat alone and avoid other staff members • May have forgetfulness or confusion • May have a “glossed over” look or doesn’t keep up on their personal appearance

8. Additional signs a co-worker has a drug problem • The co-worker may be defensive when asked about medication errors • Waits alone for the narcotic cabinet to be opened and frequently disappears after use • Always volunteers to be the medication nurse • May have many patients complain that their pain medication is not effective

9. VIDEO OF AN ADDICTED NURSE http://www.youtube.com/watch?v=diFtEzZ6hGs

10. Identifying if a nurse is addicted to alcohol • There are several clues to tell if a nurse is addicted to alcohol and is abusing while working • The nurse may: • Drink many sodas • Chew gum or use breath mints to cover up the smell • Have flushed face or blurry eyes • Slurred speech or unsteady gait

11. What should you do? • Deal with the problem as soon as you know it exists • Notify your immediate supervisor • Document everything! Note each time the activity what was observed, what you said to the nurse and what action the employee took, observe signs objectively, not judgmentally, document errors, slurred speech, uncontrollable anger or poor coordination-it’s a good idea to have a 2nd person present • If you were her supervisor, you should remove the nurse from the situation and confront her in private • If possible send him/her home or put them somewhere where they can rest and have them be transported home by a friend or relative • Listen to the nurse, allow her to explain, let her know that she needs to take some time off to get better and that she needs to improve before she can come back

12. Do’s and don’t’s • Don’t do nothing • Don’t put off dealing with the problem, it won’t get better with time • Don’tlecture, scold, blame, lose your temper, be overly sympathetic or threaten the • Don’t enable the problem to continue by covering for the nurse, trying to protect her or by making excuses • Don’t give the person an easier work schedule • Don’t accept promises like “I’ll do better.” Tell them they are in danger of suspension or termination and that if performance doesn’t improve, you will have to follow through

13. Legal issues • Chemical dependence among nurses raises many legal and ethical questions • Impaired practice results in financial implications such as absenteeism, quality of care issues such as preventable errors, and its impact on staff morale affects nurse retention

14. Legal Issues: A Case Study • Two doctors and three nurses smelled alcohol on the nurse’s breath. She slurred her speech, mispronounced patient’s one syllable first names, had problems with equilibrium and laughed inappropriately

15. Legal issues: a case study • When confronted she became highly belligerent. She refused to give blood or urine samples in the E.R. even as the E.R. nurse explicitly told her that her refusal would mean automatic termination.Instead, the nurse phoned her attorney and got into a highly agitated conversation. • WHAT DO YOU THINK? • What did the court do? Upheld the nurse? Or the nurse’s employer?

16. Legal issues: a case study • The court upheld the nurse’s employer’s strict policy. When there is reasonable suspicion a nurse is intoxicated or chemically impaired on the job and the nurse refuses a blood or urine screening, the nurse’s refusal is automatically considered a positive drug test and an act of insubordination justifying termination. • The State Board of Nursing can consider a nurse’s refusal as positive proof of intoxication or impairment and take appropriate disciplinary action.

17. Legal issues: a case study • The court rejected the nurse’s testimony.. she was so shocked at being asked to be tested that she did not know what to do as well as her claim she was using “over-the-counter cough medication” • The court also noted that a simple misdemeanor offense is grounds for license suspension and termination for a nurse if it involves harm to a person. Kraft v. State Board of Nursing, 631 N.W. 2d 572 (N.D., 2001).

18. Reasons why people become addicted *Approximately 10% to 15% of all healthcare professionals will misuse drugs or alcohol at some time during their career.

19. History of addiction in the nursing profession • Viewed as morally weak and not fit to practice • Boards of nursing imposed discipline on the chemically dependent nurse • which invariably led to probation, suspension, or permanent revocation of the license • In 1982 &1984, the American Association of Nurses (ANA) passed resolutions promoting treatment before disciplinary action was taken

20. Getting back into the work force • Prior to completing treatment, Health Care Professionals (HCP) undergo a practice assessment to examine their ability to return to work: • Assessment provides the opportunity to establish the risks of returning to practice to determine a treatment plan supportive of abstinence in the workplace • Address relapse prevention • Initiate decision-making about timing of return to practice

21. Getting back into the work force • Some people go right back to the workplace • others require further treatment or a period of abstinence prior to returning to work • Some will have to consider a different type of practice or another specialty • A small group of people will not return to the practice of medicine

22. Getting back into the work force • The decision to return to work is difficult and requires the expertise of a treatment team • Several factors predict relapsein HCPs, including: • positive family history for addiction/alcoholism • a psychiatric illness in addition to addiction • use of a major opioid and a psychiatric illness • use of a major opioid, a psychiatric illness and a positive family history

23. Patient safety • When a nurse is abusing drugs in the workplace he/she may be creating an unsafe environment for the patients on the unit such as: • Forgetting to lower the bed • Not putting up side rails for safety before exiting the room • Forgetting to give out medications or not giving the correct medication to the correct patient

24. Patient Safety Continued • Not assessing the patient properly • Missing signs and symptoms of the patient getting worse • Documentation may not be accurate • Communication with the patient and his/her family may not be appropriate

25. International Nurses Society on Addictions(http://www.intnsa.org/)for nurses with addictive disorders including alcohol, drug or nicotine dependencies, eating disorders and process addictions such as gambling • American Society of Addiction Medicine(http://www.asam.org/) • National Organization of Alternative Programs(http://www.alternativeprograms.org/) • Nurses in Recovery (www.brucienne.com/nir)This is an organization for recovering nurses

26. References • Chemically impaired nurse: court upholds employer’s right to demand blood test, terminate nurse for refusal. (2001). Legal Eagle Eye Newsletter, 18(10), Retrieved from http://www.nursinglaw.com/oct10brk7.pdf • Hacker. 2011. In Merriam-Webster.com. Retrieved June 20, 2011, from http://www.merriam- webster.com/dictionary/addiction • Jefferson, L.V. & Ensor, B. E. (1982). Confronting a Chemically-Impaired Colleague. The American Journal of Nursing, 82(4), 573-577 • Monroe, T. & Pearson, F. (2009). Treating Nurses and Students with Chemical Dependency: Revising Policy in the United States for the 21st Century. International Journal of Mental Health Addiction. 530-540. Doi: 10.1007/s11469-009-9208-2 • Trinkoff, A. M., Storr, C. L. & Wall, M. P. (1999). Prescription-Type Drug Misuse and Workplace Access Among Nurses. Journal of Addictive Diseases. 18(1), 9-17. doi: 10.1300/J069v18n01_02