Introduction
DISPLAY 25.4 Characteristic Changes in Chemically Impaired Employees
Changes in Personality or Behaviors
Increased irritability with patients and colleagues, often followed by extreme calm Social isolation; eats alone, avoids unit social functions
Extreme and rapid mood swings
Euphoric recall of events or elaborate excuses for behaviors Unusually strong interest in narcotics or the narcotic cabinet Sudden dramatic change in personal grooming or any other area Forgetfulness ranging from simple short-term memory loss to blackouts
Change in physical appearance, which may include weight loss, flushed face, red or bleary eyes, unsteady gait, slurred speech, tremors, restlessness, diaphoresis, bruises and cigarette burns, jaundice, and ascites
Extreme defensiveness regarding medication errors Changes in Job Performance
Difficulty meeting schedules and deadlines Illogical or sloppy charting
High frequency of medication errors or errors in judgment affecting patient care Frequently volunteers to be medication nurse
Has a high number of assigned patients who complain that their pain medication is ineffective in relieving their pain
Consistently meeting work performance requirements at minimal levels or doing the minimum amount of work necessary
Judgment errors
Sleeping or dozing on duty
Complaints from other staff members about the quality and quantity of the employee’s work Disappears from the work area for long periods of time or may spend long periods of time in the
bathroom or around the medication cart Changes in Attendance and Use of Time
Increasingly absent from work without adequate explanation or notification; most frequent absence on a Monday or Friday
Long lunch hours
Excessive use of sick leave or requests for sick leave after days off Frequent calling in to request compensatory time
Arriving at work early or staying late for no apparent reason Consistent lateness
Frequent disappearances from the unit without explanation
As the employee progresses into chemical dependency, managers can more easily recognize these
behaviors. Typically, in the earliest stages of chemical dependency, the employee uses the addictive substance primarily for pleasure, and although the alcohol or drug use is excessive, it is primarily recreational and social.
Thus, substance use usually does not occur during work hours, although some secondary effects of its use may be apparent.
As chemical dependency deepens, the employee develops tolerance to the chemical and must use greater quantities more frequently to achieve the same effect. At this point, the person has made a conscious lifestyle decision to use chemicals. There is a high use of defense mechanisms, such as justifying, denying, and bargaining about the drug. Often, the employee in this stage begins to use the chemical substance both at and away from work. Work performance generally declines in the areas of attendance, judgment, quality, and interpersonal relationships. An appreciable decline in unit morale, resulting from an unreliable and unproductive worker, becomes apparent.
Indeed, research conducted by Cares, Pace, Denious, and Crane (2015) reported that nearly half (48%) of the RNs who participated in a peer assistance program reported they had used drugs or alcohol at work, and two fifths (40%) felt that their competency level was affected by their use (see Examining the Evidence 25.1).
EXAMINING THE EVIDENCE 25.1
Source: Cares, A., Pace, E., Denious, J., & Crane, L. A. (2015). Substance use and mental illness among nurses: Workplace warning signs and barriers to seeking assistance. Substance Abuse, 36(1), 59–66. doi:10.1080/08897077.2014.933725
This survey of 441 active RNs and recent participants of a peer health assistance program examined drug-related behaviors in the workplace, behavioral cues that may permit earlier identification of substance use,
perceptions of barriers to seeking assistance, and strategies for preventing problems and overcoming barriers to seeking assistance.
Of the 256 individuals who indicated seeking services because of an alcohol or drug problem, 247 individuals responded to additional questions about their alcohol and drug use. Fifty-five percent reported using alcohol, and 50%
reported using opiates at the time of seeking services. Other drugs abused were benzodiazepines (9%), cocaine (8%), marijuana (8%), amphetamines (7%), and tramadol/soma (5%). Write-in responses indicated that participants also used diet pills and antidepressants.
One quarter of respondents (25%) indicated that they obtained drugs in the workplace; of these respondents, 12% reported that they ordered drugs for their own use, 9% obtained waste from “sharps” containers, 8% replaced drugs they had taken with other drugs, and 4% forged prescriptions. Two respondents (<1%) reported that they replaced sterile needles with used needles.
Nearly half (48%) of the respondents (69% response rate) reported drug or alcohol use at work, and two fifths (40%) felt that their competency level was affected by their use. Twenty-seven percent of respondents acknowledged that patients were put at risk one or more times because of their substance use.
More than two thirds of respondents thought their problem could have been recognized earlier. The most highly rated barriers to seeking assistance for substance use included fear and embarrassment and concerns about losing one’s nursing license. Factors that helped participants overcome these barriers included greater knowledge of ability to maintain professional license, support by friends, greater confidentiality in process of seeking assistance, support by professional colleagues, support by spouse/partner, and greater knowledge of treatment services.
Respondents recommended greater attention be paid to early identification of risk factors during nurses’ professional training as a prevention strategy. These data also suggested a need for more research to explore the prevention and early identification of co-occurring disorders in health care settings where nurses practice.
In the final stages of chemical dependency, the employee must continually use the chemical substance, even though he or she no longer gains pleasure or gratification. Physically and psychologically addicted, the employee generally harbors a total disregard for self and others. Because the need for the substance is so great, the employee’s personal and professional lives focus on the need for drugs, and the employee becomes unpredictable and undependable in the work area. Assignments are incomplete or not done at all, charting may be sloppy or illegible, and frequent judgment errors occur. Because the employee in this stage must use drugs frequently, signs of drug use during work hours may be seen. Narcotic vials are missing. The employee may be absent from the unit for brief periods with no plausible excuse. Mood swings are excessive, and the employee often looks physically ill.
The bottom line is that chemically impaired employees should be removed from the work setting long before they reach this stage. The reality, however, is that the identification of chemical impairment is often very difficult. Nursing school courses generally focus on the physiological effects of alcohol and other drugs, dealing little with the psychological process of addiction and even less with chemical dependency in nurses.
Only two states—Delaware and West Virginia—require RNs to complete continuing education on substance abuse (Starr, 2015). Because of this limited knowledge about chemical impairment, many nurses are ill- prepared to deal with chemical impairment.
Confronting the Chemically Impaired Employee
Unlike most alcoholics or intravenous (IV) narcotic users, health-care professionals do not achieve tacit peer acceptance of their addictive behavior. Thus, physicians and nurses are much less likely to admit, even to
colleagues, that they are using—much less that they are addicted to—a controlled substance. Frequently, they deny their chemical impairment even to themselves.
This self-denial is perpetuated because nurses and managers traditionally have been slow to recognize and reluctant to help these colleagues. Jason (2015) notes that many coworkers are hesitant to report the suggested chemical impairment of colleagues due to the cultural norms of their workplace. “Perhaps a co-worker is going through some particularly difficult situation and the rest of the staff may want to ‘carry’ this co-worker until they get past the current issue. The work group may feel that to report would be a betrayal of the group trust and the individual observing the behavior/symptoms does not want to report for fear of group retaliation.
There may also be the desire to just send someone home and ‘let them sleep it off,’ particularly if it appears to be a single occurrence” (Jason, 2015, p. 7).
Lillibridge (2017) agrees, noting that it is a difficult and often traumatic experience for a nurse to report an impaired peer. The important considerations are that patients are not harmed, the nurse is helped, and the provider is protected. Licensee impairment is a public safety issue as well as a personal issue (Jason, 2015).
All but a few State Boards of Nursing now have treatment programs for nurses (discussed later in this chapter), and as managers gain more information about chemical impairment, how to recognize it, and how to intervene, more employees are being confronted with their impairment.
The first step in dealing with the chemically impaired employee actually occurs before the confrontation process. In the data- or evidence-gathering phase, the manager collects as much hard evidence as possible to document suspicions of chemical impairment in the employee. All behavior, work performance, and time and attendance changes presented in the displays in this chapter should be noted objectively and recorded in writing. If possible, a second person should be asked to validate the manager’s observations. In suspected drug addiction, the manager also may examine unit narcotic records for inconsistencies and check to see that the amount of narcotic the nurse signed out for each patient is the same as the amount ordered for that patient.
Because few nurses drink alcohol while on duty, managers have to observe for more subtle clues, such as the smell of alcohol on the employee’s breath. If the organization’s policy allows for it, the manager may wish to require an employee suspected of chemical impairment to undergo immediate drug or alcohol testing. If the employee refuses to cooperate, the organization’s policy for documenting and reporting this incident should be followed.
Proving alcohol impairment is often more difficult than detecting drug impairment, as an employee can generally hide alcoholism more easily than drug addiction.
If at any time the manager suspects that an employee is chemically influenced and thus presents a potential hazard to patient safety, the employee must be immediately removed from the work environment. The manager should decisively and unemotionally tell the employee that he or she will not be allowed to return to the work area because of the manager’s perception that the employee is chemically impaired. The manager should arrange for the employee to be taken home so that he or she does not drive while impaired. A formal meeting to discuss this incident should be scheduled within the next 24 hours.
This type of direct confrontation between the manager and the employee is the second phase in dealing with the employee suspected of chemical impairment. Although some employees admit their problem when directly confronted, most use defense mechanisms (including denial) because they may not have admitted the problem to themselves. Indeed, individuals with a history of substance abuse have often become quite good at deception regarding their drug use.
Denial and anger should be expected in the confrontation. If the employee denies having a problem, documented evidence demonstrating a decline in work performance should be shared. The manager must be careful to keep the confrontation focused on the employee’s performance deficits and not allow the discussion to be directed to the cause of the underlying problem or addiction. These are issues and concerns that the manager is unable to address. The manager also must be careful not to preach, moralize, scold, or blame.
Confrontation always should occur before the problem escalates too far. However, in some situations, the manager may have only limited direct evidence but still may believe that the employee should be confronted because of rapidly declining employee performance or unit morale. There is, however, a greater risk that confrontation at this point may be unsuccessful in terms of helping the employee. If direct confrontation is
unsuccessful, it may have been too early; the employee may not have been desperate enough or may still be in denial. In these situations, job performance will probably continue to be marginal or unsatisfactory, and progressive discipline may be necessary. If the employee continues to deny chemical impairment and work performance continues to be unsatisfactory despite repeated constructive confrontation, dismissal may be necessary.
The last phase of the confrontation process is outlining the organization’s plan or expectations for the employee in overcoming the chemical impairment. This plan is similar to the disciplinary contract in that it is usually written down and clearly outlines the rehabilitative measures that should be undertaken by the employee and consequences if remedial action is not sought. Although the employee is generally referred informally by the manager to outside sources to help deal with the impairment, the employee is responsible for correcting his or her work deficiencies. Timelines are included in the plan, and the manager and employee must agree on and sign a copy of the contract.
The Manager’s Role in Assisting the Chemically Impaired Employee
Clearly, the incidence of chemical impairment in health professionals is substantial. On a personal level, a person suffers from an illness that may go undetected and untreated for many years. On a professional level, the chemically impaired employee affects the entire health-care system. Nurses with impaired skills and judgment jeopardize patient care. The chemically impaired nurse also compromises teamwork and continuity as colleagues attempt to pick up the slack for their impaired team member. The personal and professional cost of chemical impairment demands that nursing leaders and managers recognize the chemically impaired employee as early as possible and intervene.
Because of the general nature of nursing, many managers find themselves wanting to nurture the impaired employee, much as they would any other person who is sick. However, this nurturing can quickly become enabling. The employee who already has a greatly diminished sense of self-esteem and a perceived loss of self-control may ask the manager to participate actively in his or her recovery. This is one of the most difficult aspects of working with the impaired employee. Others who have greater expertise and objectivity should assume this role.
LEARNING EXERCISE
25.6
The Chemically Impaired Colleague
W
rite a two-page essay that speaks to the following: Has your personal or professional life been affected by a chemically impaired person? In what ways have you been affected? Has it colored the way that you view chemical abuse and chemical impairment? Do you believe that you can separate your personal feelings about chemical abuse from the actions that you must take as a manager in working with chemically impaired employees? Have you ever suspected a work colleague of chemical abuse? What, if anything, did you do about it? If you did suspect a colleague, would you approach him or her with your suspicions before talking to the unit manager? Describe the risks involved in this situation.The manager must be very careful not to assume the role of counselor or treatment provider for the impaired nurse.
The manager also must be careful not to feel the need to diagnose the cause of the chemical addiction or to justify its existence. Protecting patients must be the top priority, taking precedence over any tendency to protect or excuse subordinates. The manager’s role is to clearly identify performance expectations for the employee and to confront the employee when those expectations are not met. This is not to say that the manager should not be humanistic in recognizing the problem as a disease and not a disciplinary problem or that he or she should be unwilling to refer the employee for needed help. Although the manager may suggest appropriate help or refer the impaired employee to someone, a manager’s primary responsibility is to protect patients and then to see that the employee becomes functional again and can meet organizational expectations before returning to work.
The manager can play a vital role in creating an environment that decreases the chances of chemical impairment in the work setting. This may be done by controlling or reducing work-related stressors whenever possible and by providing mechanisms for employee stress management. The manager also should control drug accessibility by implementing, enforcing, and monitoring policies and procedures related to medication distribution. Finally, the manager should provide opportunities for the staff to learn about substance abuse, its detection, and available resources to help those who are impaired.
LEARNING EXERCISE
25.7
Working Under the Influence
T
here have been rumors for some time that Mr. Clark, one of the night nurses on the unit you supervise, has been coming to work under the influence of alcohol. Fellow staff have reported the odor of alcohol on his breath, and one staff member stated that his speech is often slurred. The night supervisor states that she believes, “This is not my problem,” and your night charge nurse has never been on duty when Mr. Clark has shown this behavior. This morning, one of the patients whispered to you that he thought Mr. Clark had been drinking when he came to work last night. When you question the patient further, he states, “Mr.Clark seemed to perform his nursing duties okay, but he made me nervous.” You have decided that you must talk with Mr. Clark. You call him at his home and ask him to come to your office at 3 PM.
A S S I G N M E N T:
Determine how you are going to approach Mr. Clark. Outline your plan and provide rationale for your choices. What flexibility have you built into your plan? How much of your documentation will be shared with Mr. Clark?
The Recovery Process
Although most authorities disagree on the name or number of steps in the recovery process, they do agree that certain phases or progressive observable behaviors suggest that the person is recovering from the chemical impairment. In the first phase, the impaired employee continues to deny the significance or severity of the chemical impairment but does reduce or suspend chemical use to appease family, peers, or managers. These employees hope to reestablish their substance abuse in the future.
In the second phase, as denial subsides, the impaired employee begins to see that the chemical addiction is having a negative impact on his or her life and begins to want to change. Frequently, people in this phase are buoyant with hope and commitment but lack maturity about the struggles they will face. This phase generally lasts for about 3 months.
During the third phase, the person examines his or her values and coping skills and works to develop more effective coping skills. Frequently, this is done by aligning himself or herself with support groups that reinforce a chemical-free lifestyle. In this stage, the person realizes how sick he or she was in the active stage of the disease and is often fraught with feelings of humiliation and shame.
In the last phase, people gain self-awareness regarding why they became chemically addicted, and they develop coping skills that will help them deal more effectively with stressors. As a result of this, self- awareness, self-esteem, and self-respect increase. When this happens, the person can decide consciously whether he or she wishes to or should return to the workplace.
State Board of Nursing Treatment Programs
Although chemical dependency can impair nurses’ physical, psychological, social, and professional
functioning, the problem was largely ignored until the late 1970s and early 1980s. Since that time, assistance occurs primarily in the form of diversion programs (also called intervention or peer assistance programs). A