Course for Nursing Worksite Monitors

Course for Nursing Worksite Monitors

Substance Abuse problems among registered nurses are not uncommon. The American Nurses Association in 1984 estimated that 6-8% of registered nurses use either alcohol or drugs to an extent sufficient to impair their professional judgment. Researchers Trinkhoff and Storr (1999) published the results of the first empirical estimate of the number of registered nurses with substance abuse problems. They estimated that 6.4% of registered nurses have a history of substance abuse. With over 2.9 million nurses in this country, the issues related to substance abuse are a major concern to the profession of nursing and for the safety and protection of the public they serve. In 1996, the South Dakota Board of Nursing joined with other health related Regulatory Boards to create an assistance program for recovering healthcare professionals who recognize their illness.

All participants in the HPAP program are required to have a monitor in the worksite in order to return to practice. Only nurse managers and supervisors are allowed to serve in the capacity of a worksite monitor.

As a worksite monitor for this program, you are in a unique position to assist recovering nurses to remain in the workforce and to ensure patient safety through a program of close monitoring.

Course for Nursing Worksite Monitors

Module 1. Overview of the South Dakota Health Professionals Assistance Program - A Multidisciplinary Program for Chemically Impaired Health Professionals

Module 1 Course Material

Overview of the South Dakota Health Professionals Assistance Program

– A Multidisciplinary Program for Chemically Impaired Health Professionals

§ Basics of the Law

§ Application to the Program

§ Program Description

§ Mission

§ Philosophy

§ HPAP Objectives

§ Admission Criteria

§ Denial of Admission

§ Termination Criteria

§ Program Services

§ Health Professionals Brochure

Course for Nursing Worksite Monitors

Module 1. Overview of the South Dakota Health Professionals Assistance Program – A Multidisciplinary Program for Chemically Impaired Health Professionals

Basics of the Law

The Health Professionals Assistance Program was created by the enactment of SDCL 36-2A titled Health Professionals Diversion Program during the 1996 Legislative session. To access the complete law, click here: http://legis.state.sd.us/statutes/DisplayStatute.aspx?Type=Statute&Statute=36-2A.

Participating

Licensing

Boards

South Dakota

§ Nursing

§ Dentistry

§ Pharmacy

§ Medical and Osteopathic Examiners

§ Certification Board for Alcohol and Drug Professionals

A Diversion Program is defined in law as a rehabilitative program designed and administered by program personnel which is available to participating health-related licensing boards in conjunction with, or as an alternative to, other sanctions which a health-related board may impose upon its licensee pursuant to disciplinary actions within its jurisdiction. South Dakota’s diversion program is called the South Dakota Health Professionals Assistance Program.

Application to the Program

The law designates that any applicant may access the diversion program by self-referral, board referral, or referral from another person or agency, such as an employee, co-worker, or family member. After admission evaluation, the diversion evaluation committee advises the applicant of:

§ Program requirements,

§ Implications of non-compliance with the diversion program, and

§ Secures the cooperation of the applicant with the diversion program.

Program Participant Records

All records of program participants are confidential and are not subject to discovery or subpoena. Only authorized program personnel and diversion evaluation committee members may have access to participant records unless the participant voluntarily provides in writing for release of information.

A participating licensing board may only access records of participating licensees:

§ who were referred by that licensing board,

§ who refused to cooperate with the program, or

§ who were terminated from the program.

Liability Issues

Pursuant to SDCL 36-2A-13, any person, agency, institution, facility or organization making reports to the participating board or diversion program regarding an individual suspected of practicing while impaired or reports of a participant’s progress or lack of progress in the diversion program is immune from all civil liability for submitting a report in good faith to the diversion program.

Basics of the South Dakota Health Professionals Assistance Program

Program Description

The State of South Dakota Health Professionals Assistance Program is a professionally staffed, confidential program designed to monitor the treatment and continuing care of regulated health professionals who may be unable to practice with reasonable skill and safety if their illness of Chemical Dependency is not appropriately managed. The program provides a non-disciplinary option for participating health licensing boards to deal with impaired regulated health professionals who recognize their illness and the need for continuing care and/or practice limitations.

Mission

The South Dakota Health Professionals Assistance program is dedicated to enhancing public safety and support for regulated healthcare professionals by facilitating the early intervention, treatment, and safe return to practice of health professionals whose functioning is impaired by the use of alcohol and/or other drugs.

Philosophy

The Health Professionals Assistance Program believes that the harmful involvement with alcohol and other drugs causes a negative effect on the physical, mental, social, vocational, intellectual, emotional, and spiritual areas of an individual’s life. The Program recognizes that impaired health professionals are individuals who have dedicated their lives to helping others and are now in need of help, and acknowledges that facilitating the acquisition of this help must remain a primary goal of the Health Professionals Assistance Program. The Program follows a non-punitive approach in which the program staff works in conjunction with, or as an alternative to, other sanctions which a health related board may impose upon the individual health professional.

The Health Professionals Assistance Program acknowledges a primary concern for public safety. The Program attempts to ensure public safety by providing a voluntary, confidential alternative to those chemically impaired health professionals who might otherwise go undetected. Program staff recognizes that when the health professional denies a problem, necessary action must be taken for the protection of both the professional and those persons entrusted to his or her care.

Objectives

The South Dakota Health Professionals Assistance Program strives to:

§ Ensure public health and safety through a program that provides close monitoring of health professionals who are impaired due to chemical dependency.

§ Provide a voluntary alternative to the traditional disciplinary process for individuals who meet eligibility requirements.

§ Increase self-reports by regulated healthcare professionals who recognize how their illness has impacted or may impact ability to practice with reasonable skill and safety.

§ Increase referrals by others regarding illness and illness related behavior.

§ Establish timely practice restrictions in select cases that are related to illness, thus enhancing public protection.

ADMISSION CRITERIA

A health professional may access the Program by self-referral, board referral, or referral from another person or agency, such as an employer, co-worker, or family member.

Admission is available to an individual who:

§ uses alcohol and/or drugs in a manner which may affect the ability to practice safely

§ holds licensure as a healthcare professional from a participating board in South Dakota

§ is eligible for and in the process of applying for licensure from a participating board in South Dakota

§ has been accepted as a student in a program leading to licensure as a healthcare professional

DENIAL OF ADMISSION

Admission may be denied if the individual:

§ Is not eligible for licensure in the state of South Dakota;

§ Diverted controlled substances for other than personal use;

§ Creates too great a risk for the healthcare consumer by participating in the Program, as determined by program staff and the Evaluation Committee;

§ Has problems related to sexual misconduct; or

§ Has been terminated from this or another state diversion program for noncompliance with the program requirements.

The Program will report individuals who have been denied admission to the Health Professionals Assistance Program to the applicable participating board.

TERMINATION CRITERIA

The Program may terminate an individual’s participation in the Program:

§ Based upon successful completion of the program monitoring plan.

§ Based upon failure to cooperate or to comply with the program monitoring plan.

§ If the Program receives information indicating other possible violations of that individual’s governing practice act.

PROGRAM SERVICES

Health Professional Assistance Program develops an individualized Program Participation Agreement that monitors compliance of the chemically impaired professional to the prescribed program. Monitoring can be facilitated in the following ways:

ü Referrals for evaluation and/or treatment

ü Documented continuing care plan

ü Worksite Monitors

ü Support Group Attendance

ü Practice Restrictions

ü Unscheduled Drug Screening

ü Filing of Reports to Document Compliance

ü Contract for Program Requirements

Health Professionals Assistance Program Brochure

Course for Nursing Workforce Monitors

Module 2. Recognizing the Signs of Chemical Dependency

Module 2 Course Material

Module 2. Recognizing the Signs of Chemical Dependency

§ Stages of Chemical Dependency: Initiation, Escalation, Maintenance, Discontinuation & Relapse, Recovery

§ Recognizing Impaired Practice – Behavioral Signs

§ Signs that the Professional may be Diverting Drugs

§ Responding to Suspected Substance Abuse in the Workplace

Course for Nursing Workforce Monitors

Module 2. Recognizing the Signs of Chemical Dependency

I. Stages of Chemical Dependency

According to Coombs (1997), a noted expert in the field of drug-impaired professionals, addiction does not become full blown at first use. As a worksite monitor, it is important for you to understand that physical and psychological dependence evolve developmentally. The typical stages include initiation, escalation, maintenance, discontinuation, relapse, and recovery. The developmental stages as described by Coombs are as follows:

Initiation

This stage involves three realities.

1^st The first reality is experimentation, which typically begins in adolescence, often during the first years of college;

2^nd The second reality is that the experience is a social one; and

3^rd The third reality involves use of gateway drugs such as alcohol, marijuana, and tobacco, which typically precede use of hard drugs.

Escalation

This stage of addiction is characterized by increased use of and preoccupation with drugs, along with association with other drug users. This stage begins when drug use becomes more frequent. As in the initiation stage, drug use occurs primarily in social settings. This is the stage where physiological tolerance develops as favorable attitudes toward drug use develop. The drug escalation is a gradual process.

§ At this stage, the user regards drinking and drugging as entirely normal behavior and a healthy recreational outlet.

§ The drug user feels little or no concern about the drug use and how it may impact the future.

§ The initiation stage taught the user that alcohol/other drugs relieve inhibitions and discomfort.

§ During the escalation stage, drugs are used to seek social rewards. This stage is characterized by social rewards greatly outweighing the unpleasant consequences of using.

§ Users in the escalation stage increasingly turn to chemicals for the psychological rewards of feeling adequate, masking unhappy feelings, increasing energy and fostering feelings of success.

Maintenance

At this stage, addiction has occurred and all other life activities become secondary to drugs. Psychologically dependent addicts are preoccupied with and compulsively driven by drug use. Behaviors are often deceitful and aimed at covering up the problem. As tolerance for the drug increases, an addict shifts from drug use for feeling high to use for feeling normal.

§ Professionals who use drugs at this stage are not using them for recreation, but rather in order to function. Their life is focused on drugs and their professional activities shift to a primary means to get drugs.

The maintenance stage is characterized by a change from the social context of drug use to solo use.

§ The professional becomes socially isolated because of the drug use from others.

This state is also characterized by stashes, secrets, and cover-ups. Staying one step ahead of trouble becomes a way of life for the addict. The addict’s lifestyle evolves through a sequence of seeking euphoria followed by a desire to just feel normal and, finally, a struggle to survive. Physical health deteriorates at the final phases of this stage and problems of withdrawal, desperation, and panic take over the addict’s life.

Discontinuation and Relapse

Professionals move from the maintenance stage to discontinuation through different events and circumstances which include:

§ Overdosing

§ Exhaustion and despair

§ Legal pressures

§ Job pressure

§ Pressure from family and friends

It is at this point that many nurses are experiencing issues with the licensing board as well, and may find themselves facing disciplinary action. For some professionals, recognition of the problem and independent action lead to discontinuation. Relapse is included by Coombs (1997) in this stage of addiction, although he notes that some addicts relapse many times, and others bypass relapse altogether and remain clean and sober.

Recovery

Recovery stage begins when an addict discontinues the use of drugs. Physical recovery occurs before emotional growth and recovery. Addicts who discontinue drug use have to learn healthy ways to deal with anguish and pain. Destructive habits must be replaced with healthy ones. Emotional growth comes from facing up to stressful events and consistently trying to improve. Many addicted professionals describe recovery as a spiritual awakening. As the addict recovers, family issues frequently mend and there are successes at work. Many addicts find a high level of support when they transition back to work and develop new associates and service opportunities.

II. Recognizing Impaired Practice – Behavioral Signs

Diana Quinlan, (1999), Peer Assistance Educator and Consultant, writes that suspicion of chemical dependency should not be presumed by a single sign or symptom, but rather by changes in behavior. She suggests that because the career is so sacred to the healthcare professional and the workplace is often the place of drug procurement, evidence of the disease on the job indicates a late stage of illness. Quinlan indicates that workplace problems are a last step in a downward spiral and perhaps one of the reasons that co-workers are so shocked when the illness is uncovered. She describes a “white coat syndrome” characterized by fear of punishment and fear that bad press will impact everyone, which perpetuates a code of silence that prevents professionals from receiving the help that they need to recover.

South Dakota Health Professionals Assistance Program has identified guidelines to assist employers of healthcare professionals in recognizing substance abuse in the workplace. These guidelines are divided into pre-employment and employment indicators.

Pre-Employment Indicators

Chemical dependency should not be presumed by a single sign or symptom, but rather by changes in behavior.

Numerous job changes in last 3-5 years	Inappropriate references
· Frequent relocations	· Inappropriate job qualifications
· Frequent hospitalizations	· Tendency to prefer night shift duty
· Elaborate and complicated medical history	· Reluctance to submit to a physical examination
· Unexplained time lapses in life	· Reluctance to submit to a physical examination

Employment Indicators

ü Absenteeism

§ Leaving without permission

§ Excessive sick leave

§ Frequent Monday and/or Friday absences

§ Repeated absences, particularly if they follow a pattern

§ Lateness at work, especially on Monday mornings and/or returning from lunch

§ Leaving work early

§ Peculiar and increasingly unbelievable excuses for absences or lateness

§ Absent more often than other employees for colds, flu, gastritis, etc.

§ Frequent unscheduled short-term absences with or without medical explanation

ü “On the Job” Absenteeism

§ Continued absences from unit more than job requires

§ Text Box: ü Confusion
§ Difficulty following instructions
§ Increased difficulty handling complex assignments Long coffee breaks, lunch breaks

§ Repeated physical illness on the job

§ Frequent trips to the bathroom

§ Frequent coffee breaks taken alone

ü Uneven Work Patterns

§ Alternate periods of high and low productivity

§ Change from volunteering to work extra to doing only minimal work

ü High Accident Rate

§ Accidents on the job

§ Accidents off the job which affect job performance

§ Horseplay which causes unsafe conditions

ü Problems with Memory

§ Difficulty in recalling instructions, details, conversations

§ Difficulty in recalling one’s own mistakes

ü Difficulty in Concentration

Reporting to Work in Altered or Impaired Condition

ü General Lowered Job Efficiency

§ Missed deadlines

§ Complaints from patients and their family members

§ Improbable excuses for poor job performance

§ Cannot be depended on to be where they say they will be, or to do what they say they will do – unreliable

§ Shuns job assignments and/or incomplete assignments

ü Poor Employee Relationships

§ Failure to keep promises and unreasonable excuses for failing to keep promises

§ Over-reaction to real or imagined criticism

§ Borrowing money from co-workers

§ Unreasonable resentments

§ Avoidance of associates

§ Lying and exaggerating

§ Complaints from co-workers, supervisors, and other staff

§ Blames others for problems

ü Appearance

§ Decreasing attention to personal appearance and hygiene

§ Odor of alcohol on breath

§ Glassy, red eyes

§ Tremors

§ Unsteady gait or slurred speech

ü Other Behaviors

§ Sleeping on the job

§ Withdraws from others

§ Mood swings

§ Increased irritability

§ Relates problems at home, with relationships, with finances

§ Preference to work alone or eat alone

§ Excessive use of breath mints

§ May drink sodas frequently

§ Frequently solicits physicians for “hallway prescriptions”

§ Frequently visits ER for various physical problems requiring pain medications

III. Signs that the Professional May be Diverting Drugs

q Always volunteers to give medications

q Patients complain of no pain relief from medications given

q Discrepancies on medication administration records

q Always gives IM PRN and maximum doses when other nurses do not

q Has frequent wastage, such as spilling drugs or breaking vials

q Unobserved wastage – no co-signature

q Is working on a unit where drugs are missing or have been tampered with

q Frequently volunteers for additional shifts and on unit when not assigned

q Excessive amount of narcotics sign out to patients

q Volunteering to care for patients who have regular pain medications

q Selected patients will only receive sleeping pills and narcotics when nurse is on duty

q Abnormal number of syringes used or missing

q Evidence of broken syringes in employee restroom

q Borrows narcotics from other units

q Narcotics signed off controlled substance record but not recorded on patient record

IV. Responding to Suspected Substance Abuse in the Workplace

The goals in identification of an impaired colleague are to assure the safety of those patients who have been entrusted to his or her care, to assist the nurse to gain treatment for the illness, and to eventually transition back to practice once the nurse has documented recovery. Quinlan (2003) identifies that documentation of performance and behavior of a suspected colleague is essential for the objective evaluation of the situation, as well as crucial to an effective resolution or intervention. Individuals in supervisory positions should be the person(s) confronting the chemically dependent nurse, since the supervisor has the authority to present the options of termination, reporting to the state board of nursing, and treatment intervention. Pullen and Green (1997) have reported that when given these choices, the nurse usually accepts intervention. Nursing managers or supervisors should be involved when the nurse returns to work.

The South Dakota Health Professionals Assistance Program allows only

nursing managers and supervisors

to be the worksite monitor for a recovering nurse to return to practice.

It is most helpful for all individuals involved if an institution has written polices and procedures in place to provide for a consistent approach to removing the impaired practitioner from the workplace and to set the parameters for possible return to practice. Miller (1997) recommends an organizational plan that:

§ Emphasizes early identification, intervention, follow-up and re-entry into practice;

§ Identifies skilled personnel to serve as consultants throughout the process;

§ Provides educational programs for the nursing administration team, staff, hospital administration, and human resources personnel addressing the prevalence of chemical dependency and the need for a supportive environment.

Course for Nursing Worksite Monitors

Module 3. Role of the Worksite Monitor

Module 3 Course Material

Module 3. Role of the Worksite Monitor

§ Worksite Monitors

§ Compliance Monitoring

§ Unscheduled Drug Screens

§ Participation Agreements

§ Monitoring Plan

§ Worksite Monitor Report Form

Course for Nursing Worksite Monitors

Module 3. Role of the Worksite Monitor

Worksite Monitors

All participants in the Health Professionals Assistance Program (HPAP) are required to have a monitor at the worksite in order to return to practice. The individual participant is responsible for informing the employer of his or her HPAP participation and for identifying a person to serve as the worksite monitor. Monitoring at the place of employment is required in order to return to practice.

Worksite Monitor Qualifications

§ Manager or Supervisor to whom individual is accountable	§ Monitor may not be an employee of or supervised by the HPAP participant or share in any fiduciary responsibility with the participant
§ Time available to participate in program	§ If Monitor is also recovering from the illness of chemical dependency, Monitor must have a minimum of 2 years* of sobriety*
§ Preferably work same hours & same location as participant	§ Complete monthly evaluation form documenting participant’s work performance
§ Willing to monitor the work performance of the participant	§ Willing to communicate with the HPAP program director

Worksite Monitor Responsibilities

§ “Keep an eye out” for the HPAP Participant

§ Provide reports and documentation of progress, or lack of, to the HPAP Director, or to the appropriate Board if necessary

§ Identify when the HPAP Participant may be in danger of relapse

§ Help transition the nurse back into the environment

§ Recognize signs & symptoms of chemical abuse and when to intervene appropriately to safeguard patients

Compliance Monitoring

A major focus of Health Professionals Assistance Program is monitoring compliance of the chemically dependent professional to the prescribed treatment program. Monitoring can be facilitated in the following ways:

§ Unscheduled drug screens

§ Contracts for program requirements

§ Worksite monitors

§ Support Group Attendance

§ Referral for treatment and continuing care

§ Practice Restrictions

§ Filing of reports necessary to document compliance

Unscheduled Drug Screens

All HPAP participants are subject to unscheduled drug screens. Each participant is required to make a daily call to find out whether he or she has been selected that day for an unscheduled drug screen. If the participant is selected for the screen, a specimen is required to be submitted within 2-6 hours of the request. Failure to comply with the drug screening requirements may result in discharge from the program.

Practice Limitations

In an effort to protect the safety of patients and to help prevent relapses, practice limitations may be established by the Health Professionals Assistance Program at any time. Examples of practice limitations are not having access to narcotics or other controlled substances or having supervision when administering controlled substances. Practice limitations may include specific units where a nurse may not practice, such as the Intensive Care Unit or the Emergency Room where access to drugs may pose a potential safety risk. Any practice limitations will be part of the monitoring plan and will be provided to the worksite monitor.

Professional Support Groups

Professional support groups are an important part of the recovery plan and help the practitioner commit to a chemical-free lifestyle. Support groups which HPAP participants attend must:

§ Believe in the total abstinence model of recovery and the twelve-step program principles

§ Maintain participant confidentiality

§ Have regularly scheduled meetings which are conducted by a qualified facilitator

HPAP staff refer participants to support groups and monitor attendance at the meetings as a condition of participation in the HPAP program. The purpose of support group participation is to provide strength, hope, and support in addressing issues related to the process of recovery from chemical dependency.

Participation Agreements

Each applicant who is accepted into the program will enter into an individualized program participation agreement within 60 days from the date of their application to the program. The purpose of the participation agreement is to provide a means of monitoring the treatment and continuing care of regulated health professionals who may be unable to practice with reasonable skill and safety if their illness of chemical dependency is not appropriately managed. The terms of the participation agreement are developed by the HPAP case manager in conjunction with the applicant, the evaluation committee, and other appropriate resources.

The individualized participation agreement consists of these components:

§ Demographic information

§ Basis for the Agreement – statement of diagnosis and source

§ Standard conditions required in all agreements

§ Illness specific conditions / monitoring requirements

§ Modification terms

§ Discharge terms

§ Board referred discharge

§ Monitoring Plan

§ Signatures

Monitoring Plan

The purpose of the monitoring plan is to ensure that the healthcare professional is competent to practice and to provide for the safety of those individuals entrusted to their care.

Terms of the participation agreement will be incorporated into a Monitoring Plan which will be provided to the:

§ Participant

§ Treating Professional/Physician

§ Worksite Monitor, and

§ Any third party the HPAP Participant designates in writing

The Monitoring Plan incorporates all of the conditions, limitations, and terms of each individualized participation agreement. Upon receipt of the signed participation agreement, the monitoring plan is developed by HPAP staff.

The monitoring plan includes recommendations for treatment and continuing care, worksite monitoring, practice restrictions, unscheduled drug testing, support group participation and filing of reports necessary to document compliance with the program. As a worksite monitor, you will be given a copy of the monitoring plan.

Worksite Monitor Report Form

As a worksite monitor, you will provide monthly reports to Health Professionals Assistance Program that include an assessment of the overall work performance of the participant. You will be asked to provide information that includes work performance, record keeping, punctuality, and professional demeanor to colleagues and other staff. The work quality assessment form includes a series of behaviors which describe unsatisfactory job performance and may help you to identify an individual who is at risk. You will be asked to assess the HPAP participant based on a series of behaviors and comment on the behaviors that you have marked as problematic. You will also be asked to describe the participant’s strengths and areas needing improvement in his or her work performance.

Course for Nursing Workforce Monitors

Module 4. Return to Work Issues

Module 4 Course Material

Module 4. Return to Work Issues

§ Responsibilities of the HPAP Participant

§ Responsibilities of the HPAP Program Director

§ Board of Nursing Involvement

§ Creating a Supportive Work Environment

§ Relapse Prevention

§ Resources for the Worksite Monitor

Course for Nursing Workforce Monitors

Module 4. Return to Work Issues

Responsibilities of the HPAP Participant

§ Informs employer of participation in the HPAP program

§ Complies with all program requirements

§ Secures a worksite monitor who is a supervisor or manager

§ Informs HPAP Director of the worksite monitor’s contact information

§ Completes all required documentation

§ Meets regularly with worksite monitor for feedback and support

Responsibilities of the HPAP Program Director

§ Determines when the HPAP participant may return to work

§ Contacts the worksite monitor and provides a copy of the participant’s monitoring plan

§ Explains any practice restrictions that are part of the monitoring plan

§ Provides the monitor with monthly work performance reporting documents

§ Serves as a resource to the worksite monitor and employing facility

Board Involvement

There are multiple routes for a healthcare professional to become involved with the South Dakota Health Professionals Assistance Program, one of which is by a mandate from the licensing Board. The Board of Nursing becomes involved when a complaint has been made regarding the performance and behavior of the nurse. An investigation is conducted and all due process requirements are followed. Disciplinary action may or may not be taken depending on the facts of the case. If a nurse is mandated into the HPAP program as a condition for licensure and is placed on probation, the Board will be monitoring the progress of the nurse. The HPAP program director submits quarterly reports to the Board indicating the nurse’s compliance with all aspects of the program. Non-compliance with program requirements may result in disciplinary action including suspension of the nursing license until such time as the licensee can demonstrate good cause as to why the license should be reinstated. Factors that influence disciplinary action include, but are not limited to, diversion of drugs from the workplace, practicing under the influence of drugs, drug substitution or alteration, and any other actions that place the public at risk.

Creating a Supportive Work Environment

Nurse Managers and Supervisors play a critical role in managing impairment issues in the workplace. As a worksite monitor, he or she must be knowledgeable, prepared, proactive, and compassionate to be most successful. In addition, managers should:

ü Maintain current knowledge of addiction & recovery

ü Set reasonable policies

ü Keep a positive attitude for work environment

ü Set clear limits that are mutually respectful and supportive

ü Educate staff about signs of impaired practice

As a nurse recovers from substance abuse, support received from co-workers and supervisors can be crucial to returning to the work environment.

The recovering nurse needs their support, understanding, and patience.

§ Physical recovery from addiction may last 6 to 24 months.

§ Emotional recovery may last 5 years.

Co-workers may have difficulty accepting the nurse returning to practice, and may experience:

§ Fear that they may do the “wrong thing” which will hinder the nurse’s recovery

§ Denial that one of their co-workers is an addict

§ Guilt related to what they could have done to prevent the addiction

§ Resentment because co-workers have extra workload due to the nurse’s practice restrictions

When resentment occurs, managers can assist the nurse’s co-workers to acknowledge their negative feelings and put those feelings into perspective. Unresolved hostility can poison an entire unit. Managers may help by setting the tone; as nurses, we must care enough to help our colleagues struggling to overcome addiction.

With collegial support and assistance,

recovering nurses can return

to nursing and contribute to the

excellence of the nursing profession.

There should be a clear policy (NCSBN, 2001) regarding the management of relapse and it should include areas of:

§ Identification

§ Documentation

§ Intervention

§ Referral for fitness to practice

§ Assessment/treatment

§ Parameters for return to practice

Written policies increase the likelihood that all nurses will be treated in a similar manner. In addition, policies protect the organization legally. Thompson, Handley, & Uhing-Nguyen (1997) identify that policies serve as a framework for intervention when impaired practice is suspected. The policy must be written from the philosophy of substance abuse with recognition of the fact that it is an illness requiring appropriate treatment. All employees should be aware of this philosophy as it promotes an environment that encourages self-referral.

The authors break down policy development into three stages:

1^st The first identifies resources

2^ndThe second establishes a committee

3^rd The third educates task force members

Components of the policy include:

§ Prevention and early intervention

§ Identification of impaired practice

§ Intervention, evaluation and treatment

§ Reentry into practice

For years, healthcare employers have fired nurses who were suspected of substance abuse, usually based on poor performance or attendance. These nurses were often lost to the profession when they could have recovered with appropriate treatment. The 1990 Americans with Disabilities Act (ADA) prohibits discrimination in the workplace because of a disability and now protects nurses recovering from substance abuse. Legally, it is important to have a therapeutic and consistent approach to the recovering nurse. By providing guidelines for recognizing signs and symptoms and an assessment tool to facilitate the policy, nurse managers and worksite monitors can more effectively provide a supportive and caring environment for the recovering nurse and staff.

Relapse Prevention

A participant experiencing relapse will be required to suspend practice for a period of time to facilitate a review/revision of the participation agreement. According to the policies of the HPAP program, Relapse:

§ is the process of becoming so dysfunctional in sobriety that, unless interrupted, a return to the addictive use is a predictable outcome;

§ is not a necessary and expected part of the recovery process; but

§ may be part of the recovery process for some, and may even be the catalyst that allows an individual to finally understand the nature of addictive disease and move beyond denial.

As part of the monitoring plan, program participants agree to immediately self-report any use of alcohol or non-prescribed mood altering chemicals. A positive drug screen is considered to be a relapse, as well as unexcused missed drug screens. A relapse may result in a restructuring of the monitoring plan or termination from the program and referral to the Board of Nursing for disciplinary review.

Relapse is a part of chemical dependency and one of the biggest challenges for recovering nurses. Relapse is a process that occurs within the patient and manifests itself in a progressive pattern of behavior that reactivates the symptoms of the disease or creates related debilitating conditions in a person that has previously experienced remission from the illness (Gorski & Miller, 1982, pp. 21-22).

Recovery means a change of habits and acquiring new skills for the return to health.

§ If the participant reverts to old behaviors, the worksite monitor should be aware that these behaviors signal that there are disturbances in thought processes, judgment, emotional reactions and a relapse may be imminent.

§ The person may lose sight of the benefits of recovery and become self-absorbed in his/her addictive behavior.

§ The person may become complacent with their program of recovery or may refuse to ask for help when it is needed.

§ It is important to understand the relapse dynamic – early identification and intervention are the best protection for the nurse’s recovery, and therefore also for the patients entrusted to the nurse’s care.

The HPAP participant must identify the things that put him or her at risk for relapse and use the various recovery tools on an ongoing basis. Some common tools for the HPAP participant are:

§ Journaling recovery progress

§ Meetings (Support Groups, AA)

§ Reaching out to friends and family

§ Prayer and meditation

§ Reading recovery books and literature

§ Plan of action when cravings or symptoms increase

§ Relaxation techniques

Resources for the Worksite Monitor

§ Chemical Dependency Handbook published by NCSBN. For details and how to purchase the book, go to: https://www.ncsbn.org/246.htm

§ NCSBN Online Learning Module: Confronting Colleague Chemical Dependency. For details and how to enroll, go to: www.learningext.com

§ Alcoholism and Substance Abuse program Branch of the Indian Health Service: http://www.ihs.gov/

§ American Association of Nurse Anesthetists – Peer Assistance Directory: http://www.aana.com/peer/directory.asp

§ Employee Assistance Professionals Association: http://www.eapassn.org

South Dakota Health Professionals Assistance Program

Nursing Worksite Monitors Orientation Course Evaluation

Thank you for participating in this Worksite Monitors Orientation Course Evaluation. To help us better meet the needs of future worksite monitors, we would appreciate your comments regarding the following questions. After completing the evaluation, please submit it to Winora.Robles@state.sd.us at South Dakota Board of Nursing.

1. Describe your knowledge of the South Dakota Health Professionals Assistance Program prior to completion of the Orientation Program.

2. Provide a summary of how this course will assist you in your role as a Worksite Monitor for recovering nurses who are returning to practice.

3. What recommendations do you have for additional content to assist worksite monitors?

4. Please provide the length of time required for you to complete this course.

5. Provide your view of the recovering nurse returning to practice. Has your perception changed as a result of completion of this course?

6. How would you describe the ease of use for this course?

7. Other comments or suggestions for the orientation program.

Bibliography

Books

Coombs, R.H. (1997) Drug Impaired Professionals. 129-163. Cambridge, MA: Harvard University Press

National Council of State Boards of Nursing Disciplinary Resources Modules Task Force. (2001). Chemical Dependency Handbook for Nurse Managers: A guide for Managing chemically dependent employees. (1^st ed.) Ellicott City, MD: Niche Communications, Inc.

Journals

Beckstead, J. (2002). Modeling attitudinal antecedents of nurses decisions to report impaired colleagues. Western Journal of Nursing Research. 24(5). 537-551.

Blair, P. (2002) Report impaired practice-stat. Nursing Management. 33(1):24-25.

Blair, P. (2005). Spot the signs of drug impairment. Nursing Management 36:2, 20-21, 52.

Bradley, K. A., MD. (1992, March). Management of alcoholism in the primary care setting. Western Journal of Medicine. 156:273-277.

Clark, C., Farnsworth, J. (2006). Program for recovering nurses: an evaluation. MedSurg Nursing 15:4, 223-230.

Clemmer, J. (1987, October). When an addicted nurse comes back to work. RN, 33 (1): 24-25.

Crowley, T. J., MD. (1984, March) Alcoholism-identification, evaluation and early treatment. Western Journal of Medicine. 140: 461-464.

Dunn, D. (2005). Substance abuse among nurses defining the issue. Journal of The Association of Perioperative Registered Nurses. 82(4). 573-599.

Domino, K. et al. (2005). Risk factors for relapse in health professionals with Substance use disorders. Journal of the American Medical Association. 293(12). 1453-1460.

Ellis, P, (1995). Addressing chemical dependency: a need for consistent Measures. Nursing Management. 26(8). 56-8.

Fiesta, J. (1997) Corporate liability update. Nursing Management, 28 (11):22- 24.

Fletcher, C. (2004). Experience with peer assistance for impaired nurses in Michigan. Journal of Nursing Scholarship 36:1, 92-93.

Griffith, J. (1999). Substance disorders in nurses. Nursing Forum. 34(4). 19-28.

Hughes, T. (1995). Chief nurse executives response to chemically dependent Nurses. Nursing Management. 26(3). 37-41.

Lillibridge, J., Cox, M., & Cross, W. (2002). Uncovering the secret: giving voice to the experiences of nurses who misuse substances. Journal of Advanced Nursing, 39 (3), 219-229.

Naegle, M. (2003). An overview of the American nurses’ associations’ action on Impaired practice with suggestions for future directions. Journal of Addictions Nursing. 14. 145-147.

Quinlan, D. (2003). Impaired nursing practice: a national perspective on peer Assistance in the u.s. Journal of Addictions Nursing. 14. 149-155.

Thompson, N., Handley, S., & Uhing-Nguyen, S. (1997) Substance abuse in nursing, forming policies. Nursing Management. 28 (2) 38, 40, 42-43.

Trinkhoff, AM, Zhou, Q., and Storr, CL. (1999). Estimation of the prevalence of substance use problems among nurses using capture-recapture methods. Journal of Drug Issues. 29(1). 187-198.

Trinkhoff, AM, and Storr, CL. (1998). Substance use among nurses: differences between specialties. American Journal of Public Health. 88(4). 581-5.

Trinkhoff, AM, and Storr, CL. (1999). Prescription-type drug misuse and work place access among nurses. Journal of Addiction Disorders. 18(1). 9-17.

Westreich, L. (2002. Addiction and the americans with disabilities act. Journal of the American Academy of Psychiatry Law. 30. 355-63.

Witkiewitz, K., PhD. Marlatt, G. A., PhD., & Walker, D., PhD. (2005). Mindfulness-Based Relapse Prevention for Alcohol and Substance Use Disorders. Journal of Cognitive Psychotherapy: An International Quarterly. 19 (3).