Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 1

Transcription

1 Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 1

2 2006, 2008 College of Registered Nurses of Nova Scotia Halifax, Nova Scotia All rights reserved. No portion of this publication may be reproduced in any form or by any means without the written permission of the copyright owner.

3 Table of Contents Introduction... 3 Purpose... 4 Denial of Problematic Substance Use... 5 Enabling Problematic Substance Use... 5 Indicators of Problematic Substance Use... 7 Case Study: Part Case Study: Part Interventions: Registered Nurses and Managers Responsibilities of Registered Nurses Responsibilities of Managers Case Study: Part Case Study: Outcome Treatment for Addiction Returning to Practice The Nurse Returning to Practice Colleagues of Nurses Returning to Practice Managers of Nurses Returning to Practice Conclusion Appendices Appendix A Definitions Appendix B Professional Conduct Process Appendix C Professional Practice Issues Resolution Framework References... 31

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5 Problematic Substance Use in the Workplace A Resource Guide for Registered Nurses INTRODUCTION According to Faltz and Skinner (2002), the term substance use refers to the use of legal substances within the bounds of socially acceptable circumstances and behaviour that does not pose any harm or risk to the individual or others. Alternatively, abuse, dependency and/or addiction involve the use of a legal or illegal substance that could cause physiologic and/or psychological harm to an individual and/or others (see Appendix A: Definitions). Some researchers have noted that nurses exhibit rates of substance use similar to those reported in other general populations, however, they have higher rates of problems with use of unprescribed prescription medications (Trinkoff et al., 1998). Based on a randomized telephone survey of the general public between December 2003 and April 2004 (Canadian Addiction Survey), drinking alcohol increased from approximately 72% in 1994 to 79% in At the same time, the proportion of Canadians reporting any use of illicit drugs in their lifetime rose from 29% in 1994 to 45% in 2004: with cannabis use rising from 23% to 45%, while the use of cocaine rose from 4% to 11%, and the use of LSD/speed/heroin from 4% to 13%. In addition, the number of Canadians who reported using an injectable drug rose from 1.7 million in 1994 to over 4.1 million in The Canadian Community Health Survey (2002) also reported an increase in the use of Ecstasy; from 3% in 2002 to 4% in In the United States it has been estimated that 10% 20% of healthcare workers are dependent upon alcohol and other drugs (Grover & Floyd, 1998). A 1992 study of American nurses reported that the incidence of alcohol or alcoholrelated problems was estimated to include 6%-20% of all practising nurses, and instances of drug dependency were estimated at 3%-5% (Markey & Stone, 1997). While there are no exact data on the number of nurses in Nova Scotia, or Canada, who are experiencing problems with substance use, slightly more than 12% (17) of the 138 complaints received by the College of Registered Nurses of Nova Scotia (the College) over the past five years were related to problematic substance use. However, because some situations are never reported to the College, the number of complaints received may not be an accurate representation of the actual number of nurses in Nova Scotia experiencing problems with substance use. In some cases, nurses employers may deal with issues related to problematic substance use through their facility s occupational health department and/ or Employee Assistance Program (EAP). However, data obtained from the College s professional conduct records does indicate that nurses have had problems with substances such as: alcohol narcotics such as Demerol, Morphine, MS Contin, Dilaudid other controlled drugs such as Tylenol#3, Darvon, and Ativan street drugs such as cocaine (including crack cocaine), cannabinoids, LSD and hashish. After an extensive literature review and consultation, the College of Registered Nurses of Nova Scotia has chosen to use the term problematic substance use in its documents and education programs rather than terms such as abuse, dependency and/or addiction. Problematic substance use, as it relates to the practice of nursing, is defined by the College as situations in which the use of a substance negatively impacts the ability of a registered nurse to practise nursing in a safe, competent, and ethical nursing manner. Recognizing that any substance use can impair a nurse s Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 3

6 practice, the College s preference for the broader definition of problematic substance use relates to its focus on early identification of problems. As problematic substance use can affect an individual s cognitive functioning and judgment, as well as her/his ability to make decisions, respond appropriately, and/or handle stress, it is considered a threat to nurses professional standards and the provision of safe, competent and ethical nursing care. If left unchecked, problematic substance use can lead to adverse circumstances for clients and nurses. According to Kim Clark, a registered nurse and College-approved addictions assessor, the nursing profession has, historically, been reluctant to identify nurses who have problems with substance use until a risk to client safety necessitates taking action. Also, a lack of collegial response and support has been linked to both professional denial and a lack of education regarding problematic substance use and addiction at every level of nursing (K. Clark, personal communication, April 2006). Unfortunately, delays in dealing with problematic substance use can result in nurses experiencing serious and multiple health/life issues. Studies of nurses in recovery programs have shown that early action provides the best chance for successful intervention and recovery (Danis, 2004). Problematic use of substances can also develop into chemical dependency and/or addiction for some individuals. Dependency and addiction to drugs and/or alcohol may be viewed as an illness that is progressive and chronic in nature, and can be fatal if not treated. Many nurses who become addicted often began using drugs to self-medicate for pain, fatigue or depression. These individuals are generally bright, ambitious and conscientious nurses. Some of these individuals may have been physically or sexually abused as children/adolescents, and developed their addiction during adolescence or as adults. Addiction is treatable but, unfortunately, because of the associated denial, shame and/or guilt, many people will not seek treatment voluntarily (CRNBC, 2004; CRNNS, 2006). For the same reasons, some people are reluctant to acknowledge that a family member, friend or colleague has a problem with substance use. PURPOSE Nova Scotia s Registered Nurses Act (2001) places an obligation on registered nurses and nurse practitioners*, individually and collectively, to practise in accordance with their Standards for Nursing Practice (CRNNS, 2003), and the Code of Ethics for Registered Nurses (CNA, 2008). The purpose of this document is to provide: 1) a resource for registered nurses and their employers, to assist them in identifying and addressing problematic substance use within the nursing profession, and 2) a framework for selfexploration and self-reflection by registered nurses experiencing problematic substance use. This document is intended to: educate nurses and employers about problematic substance use provide practical steps to address related issues in a caring and supportive manner encourage nurses who acknowledge they have a problem with substance use to seek help inform nurses of their professional responsibilities in situations where there is a risk or potential risk to patient safety as a result of a nursing colleague s problem with substance use. (* For the purposes of this document, the terms nurse or registered nurse will be used in reference to both registered nurses and nurse practitioners.) 4 College of Registered Nurses of Nova Scotia

7 DENIAL OF PROBLEMATIC SUBSTANCE USE Denial is a defining feature of addictions and the chemically dependent nurse is often the last to see that she [he] has a life-threatening illness (Hughes & Smith, 1994, p.32). Denial has been defined as a person s inability to accept: (a) the severity of the consequences associated with substance abuse; (b) a diagnosis of substance abuse or dependence; or (c) his or her loss of control over substance use (Faltz and Skinner, 2002). Basically, denial tells a person that s/he is not sick. Denial can take many forms, such as maintaining that something is not so, minimizing harmful results, blaming others or other situations, rationalizing the substance use, intellectualizing, changing the subject and/or becoming hostile. However, it is important to note that denial is not deliberate deception rather, it is a defence mechanism. Denial is most often subconscious. In other words, a person in denial may be unaware of the true nature and extent of her/ his substance use. Persons with a dependency or addiction are usually unable to admit the consequences of their problematic substance use or see the logical connection between the use of substances and the negative consequences (APTS, 2005). Denial may also be compounded by cravings: compelling urges to use a substance that dominates a person s thoughts and can affect a person s mood, behaviour and actions. Some nurses with an addiction have described these cravings as being all-encompassing, in that the need for the drug directs how they organize their workday to access drugs and hide their addiction (Lillibridge et al., 2002). In addition to denial, a common characteristic of persons with addictions is their inability to access their internal moral code. Some signs of this inability are lying, cheating, theft, diversion and manipulation in an effort to cover up their alcohol or drug use or diversion of drugs in the workplace. Every individual nurse has a moral code that effectively guides her/his decision making, however, once an addiction gains control, a person may be unable to access this moral code and will do things that they would never have considered when they were well. Once a nurse is stable in recovery, they will be able to access their moral code again (K. Clark, personal communication, April 2006). ENABLING PROBLEMATIC SUBSTANCE USE For a number of reasons, including the stigma attached to addiction, nurses may be reluctant to acknowledge to themselves or others that a member of the profession a colleague, and perhaps a friend has a problem with substance use (Hughes & Smith, 1994, p.32). Colleagues may also unintentionally contribute to an affected nurse s denial through their own denial or by enabling. Enabling allows inappropriate and non-productive behaviour in another person to go unquestioned; allowing a colleague to avoid confrontation while, in effect, encouraging and perpetuating her/his behaviour (NANB, 2003). Enabling is most often seen in nurses who have not been educated on problematic substance use or appropriate boundary setting. Motivated to help co-workers, colleagues may try to excuse or explain unacceptable performance or behaviours rather than considering the possibility that there is a problem with alcohol and/or other drugs. Colleagues may attempt to help a nursing colleague in some fashion by using enabling behaviours that serve to cover up shortcomings (e.g., follow behind or check up on the affected nurse s clients), tolerate poor interpersonal relationships, or even to try to solve the nurse s problems. Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 5

8 Nurses need to realize that the worst thing they can do for their clients or colleagues is to enable a nurse who has a problem with substance use. Enabling encourages the problematic use of alcohol and/or other drugs by shielding the person involved from the consequences of their behaviour. Enabling also delays or prevents a person from breaking through their denial to get the help that they need to deal with a substance use problem (APTS, 2005). Points to Ponder Nurses who have experienced addictions reported that easy access to drugs in the workplace contributed significantly to their use of substances as a way to cope (Lillibridge et al., 2002). Participants in one study said they were surprised at how easy it was to take discarded doses, steal patient s doses, and take medications that patients brought in from home. One of the reasons for this was the practice of other nurses. For instance, in order to ensure clients receive their pain medications in a timely basis, nurses often feel justified in taking short cuts in relation to policies on the storage and administration of narcotics. According to data collected by the College, examples of how access to narcotics is made easier and nurses with substance use problems are enabled, include when other nurses do not: actually observe the discard of controlled medications address inaccuracies in narcotic counts insist on co-signatures for wastage. When policies related to the administration and documentation of narcotics are followed it is difficult for nurses to divert drugs, and easier to identify when a nurse is attempting to divert drugs. Diversion of narcotics may be an escalation or continuation of accepted self-medication behaviours that are only viewed as being inappropriate when the magnitude and regularity of these behaviours increases (Trinkoff et al., 1999). Some addicted nurses have reported that their problems with substance use began with their taking medications such as Gravol, Tylenol #2 from hospital stocks. Some nurses and other health professionals believe that their knowledge of pharmacology and their experience administering medications and observing patients affords them greater control over their drug use (Hughes et al., 2002). Do you think allowing the practice of self-medication with hospital stock drugs is a form of enabling? A 1999 study by Trinkoff, Storr, and Wall supported the hypothesis that nurses with easier workplace access reported higher rates of substance use in three dimensions of access: perceived availability, frequency of administration, and degree of workplace control over storage and dispensing of substances. Consequently, although education alone may not be sufficient to prevent health professionals from accessing controlled substances it might be beneficial to modify the work environment regarding drug access to protect the health of nurses while maintaining performance and patient care safety standards. Modifications to workplace practices should involve input from nurses, managers and pharmacy departments and, when possible, risk management and professional practice. 6 College of Registered Nurses of Nova Scotia

9 INDICATORS OF PROBLEMATIC SUBSTANCE USE Individuals views on whether substance use is problematic are highly subjective. An individual s culture and personal experiences, as well as the type of substance use and the relationship with the person who has the problem, all influence these views (de Crispigny, 1996). Essentially, a nurse s focus should not be on attempting to diagnose a possible substance use problem, but on determining whether or not a colleague is exhibiting signs that they need help. It is also important to remember that a number of other stressors and/or medical conditions may present similar indicators to those of problematic substance use. Behaviours associated with problematic substance use can be confusing and conflicting and may, initially, be difficult to identify. In the early stages, when substance use is becoming a problem, the behaviours exhibited by a person may be similar to those of a person experiencing extreme stress or other mental/physical health issues. The following signs are common indicators of problematic substance use and may assist in the early identification of a person with a problem. However, as mentioned previously, none of these warning signs alone or in combination are necessarily indicative of problematic substance use and may, in fact, be indicators of problems other than problematic substance use. However, they are still signs of someone who is trouble and requiring a referral for help. If several of these signs are witnessed with increasing regularity over a period of time, or a more serious error occurs (such as one that jeopardized a patient s condition), it is time to act. Once signs become obvious, a nurse s problematic substance use has at least escalated and may have advanced to the later stages, including addiction. Like other diseases, it becomes more difficult to restore good health when problematic substance use has become advanced. Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 7

10 Indicators of Potential or Actual Problematic Substance Use Physical deterioration in appearance and/or personal hygiene unexplained bruises sweating complaints of headaches tremors diarrhea and vomiting abdominal/muscle cramps restlessness frequent use of breath mints/gum or mouthwash odor of alcohol on breath slurred speech unsteady gait Personality and Mental Health family disharmony; how the colleague speaks of family members mood fluctuations (e.g., swing from being extremely fatigued to perkiness in a short period of time) irritability confusion or memory lapses inappropriate responses/behaviours isolation from colleagues lack of focus/concentration and forgetfulness lying and/or providing implausible excuses for behaviour Performance and Professional Image calling in sick frequently but still working overtime moving to a position where there is less visibility or supervision arriving late for work, leaving early taking extended breaks throughout a shift; sometimes without telling colleagues they are leaving forgetfulness errors in judgment deterioration in performance excessive number of incidents/mistakes non-compliance with policies doing enough work to just get by sloppy, illegible or incorrect charting change in charting practice excessive or over compensatory charting about medications or an incident Drug Diversionary Behaviours failing to have narcotic wastage observed and /or cosigned performing narcotic counts alone tampering of packages or vials waiting until alone to open narcotic cupboard and/or draw up medication use of fictional client names on narcotic records frequent revisions and/or discrepancies on narcotic records inconsistencies between narcotic records and patients medical charts for medications administered frequent reports of lost or wasted medications requesting to be assigned to patients who receive large amounts of pain medication increased amounts of medications being ordered for her/his patients excessive administration of PRN medications to patients along with patients reports of ineffective pain relief offering to cover other nurses breaks and to medicate their patients patients medications from home going missing (CRNM, 2002; CRNNS 2006; Ponech, 2002) 8 College of Registered Nurses of Nova Scotia

11 When faced with a colleague who is exhibiting some of these warning signs, it is not uncommon for nurses to ignore the problem because they believe they may be wrongfully accusing a colleague or their reporting alone would be insufficient. However, if one person has witnessed these concerns in a colleague it is likely that other colleagues have witnessed similar situations. Discussing valid concerns and observations with a trusted colleague may serve to verify observations. If unmistakable signs of impairment are observed (e.g., obvious confusion/disorientation, alcohol on an individual s breath, slurred speech, or inability to be awakened) a manager and/or supervisor must be notified immediately and the nurse must be removed from the setting in which s/he has been providing direct patient care. The nurse should then be placed on leave until an investigation is completed. The immediate goal of nursing colleagues, mangers and/or supervisors is to protect clients from unsafe nursing care, with a secondary goal of treatment and rehabilitation of the nurse involved. Once the investigation is complete, it is important that the issues be addressed with the focus being on allowing the nurse the opportunity to seek treatment for both the problematic use of substance(s) and the underlying cause of the problem. Case Study: Part 1 This case study (which continues throughout the document) illustrates a situation in which a nurse is experiencing problems with substance use that are affecting her nursing practice. Lucy is an RN working in a busy surgical unit with a mix of junior and senior nurses. On one particular shift, Jane, one of the nurses she has worked with for 12 years, appears to be having some difficulty. Jane s appearance is unkempt and she has dark circles under her eyes. She was late coming to work that day, took extended breaks and was frustrated and impatient with her clients. In addition, Jane, who has always been conscientious about her charting, is now just scribbling down notes on loose paper to chart later. At the end of the shift, Lucy speaks to Jane and tells her that she is concerned and worried about her. When they start talking, Jane says that she is distracted because she couldn t get a caregiver for her mother who has dementia and she had to leave her alone for two hours. She says this has been an ongoing problem and she and her husband are fighting about it. In addition, Jane is unable to sleep properly. She said she doesn t want to take sleeping pills because she is afraid she could get addicted to them, so she has been taking Gravol. Jane tells Lucy that at first she only needed one Gravol to knock her out, now she is taking at least four Gravol before she can get to sleep. Jane confides that sometimes she will take a few Gravol from work because she doesn t have time to get to the drugstore after work. Jane says that taking the Gravol is no big deal because the hospital can certainly afford it, and ends off by saying that they have now made arrangements to place her mother in a home within two weeks. Jane says her all her troubles should end then. Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 9

12 What should Lucy do? Lucy tells Jane that she is concerned and worried about her situation and the impact it is having on her. She tells Jane that she knows she is a conscientious nurse, and identifies why she thinks this stress is affecting Jane s practice. They also discuss how Jane s lack of sleep and over-medication with Gravol is affecting Jane. Lucy suggests that Jane contact the EAP and/or Occupational Health. Lucy tells Jane how she used the EAP when she was having difficulties with her teenager. She says that the EAP was completely confidential and available whenever she needed. Initially, Jane is reluctant saying that she never thought that she would be the type of person to need the EAP. Jane agrees to think about it and thanks Lucy for approaching her. She says just talking about it made her feel better. Lucy says she will check back with her soon to see how she is doing. Lucy considers whether to speak to the manager, but because it appears to be a reaction to a specific situation and likely short-term, Lucy is comfortable to allow Jane time to deal with it. Lucy makes a conscious decision to observe Jane over the next weeks. What should Jane do? If, after talking about her misuse of Gravol with Lucy, Jane realizes that she may have a problem, she should contact someone for assistance and guidance. Her options include contacting a healthcare professional such as her physician, a nurse practitioner, addiction prevention and treatment services or the occupational health nurse. She could also contact her EAP provider, her union or a College practice consultant or professional conduct consultant. In the situation described, if Lucy was unsure about her own professional responsibilities to get involved when she was concerned about Jane s ability to practice safely, she should review the College s Standards for Nursing Practice (the Standards) and CNA Code of Ethics for Registered Nurses (the Code; Code of Ethics). The Standards set out the legal and professional basis for nursing and describe the desirable and achievable level of performance expected of registered nurses in their practice (CRNNS, 2003). The Code of Ethics gives guidance for decision-making concerning ethical matters, serves as means for self-evaluation and self-reflection regarding ethical nursing practice, and provides a basis for feedback and peer review (CNA, 2008). Both the Standards for Nursing Practice and the Code of Ethics emphasize that nurses are accountable to the public for competent, safe and ethical nursing practice. This accountability includes the requirement to take action in situations where client safety and well-being is potentially or actually compromised (Standard 1: Accountability). The Code (Accountability principle G, p. 18) places a responsibility on registered nurses to be attentive to signs that a colleague is unable to perform his or her duties and to take the necessary steps to protect the safety of persons receiving care. Accordingly, all nurses have a legal and ethical duty to respond to situations that may be adverse for clients. Appendix D of the Code of Ethics provides guidance for the application of the Code in situations of incompetent, unsafe and/or unethical care. Lucy could also have contacted a nursing practice consultant or professional conduct consultant at the College ( or toll-free in NS ). 10 College of Registered Nurses of Nova Scotia

13 Case Study: Part 2 A few weeks later, Lucy notes that Jane continues to look tired and has become somewhat withdrawn. Lucy hears from other staff that Jane frequently calls in sick although she still offers to work overtime. Lucy is now quite concerned about Jane s health and well-being, so she attempts to speak to Jane again about her observations. Jane tells Lucy that she s now having frequent headaches, as well as financial and marital difficulties, but then abruptly says she does not want to speak about it any further. Jane complains to Lucy that her kids and husband are getting on her back and she doesn t want the same thing happening at work. Later in the afternoon, Lucy notices that Jane loses her concentration easily and has difficulty focusing on her work. Lucy observes the charge nurse reminding Jane three times that her patient s blood work was due at 1400 hours. The charge nurse then tells Lucy that Jane s forgetfulness has been a common occurrence over the past few weeks. Later, another nurse reminds Jane that yesterday she forgot to get her discards co-signed on the narcotic control sheet. Jane laughs and says, You worked with me yesterday, could you co-sign them for me? The nurse agrees to do so because a person from pharmacy was waiting to collect the completed sheets from the narcotic record. At the end of the shift, Lucy is still concerned about Jane. However, she doesn t approach Jane again because throughout the day Jane s old self emerged Jane was eager to assist with patient care and offered to medicate patients while her colleagues went on break. How should Lucy deal with her concerns regarding Jane s behaviours at work? Jane s explanation of having headaches, as well as her financial and marital difficulties, could be the reason for her frequent sick time and lack of concentration and focus. It appears that Jane s problems are either impacting on or being impacted by her strained family relationships. On the other hand, upon review of the warning signs for problematic substance use, it appears that Jane has been exhibiting some of the signs, specifically: frequently calling in sick, while still offering to work overtime becoming somewhat withdrawn losing her concentration easily having difficulty focusing on her work failing to have narcotic control sheet co-signed offering to medicate patients for her colleagues on break personality changes throughout day asking a co-worker to co-sign a narcotic discard, when the discard was not observed. Lucy should be aware of the possibility of problematic substance use. Because of Jane s misuse and over-medication with Gravol it appears that there is a bigger issue impacting Jane s ability to provide care. continued on next page... Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 11

14 continued from page 11 How should Lucy deal with her concerns regarding Jane s behaviours at work? In this case, Lucy should approach other staff to see if they have had similar observations and compare their observations to the warning signs. If other staff members have observed some of the indicators of problematic substance use on other shifts, Lucy should encourage them to document them, and everyone should report their concerns to the manager. Proper documentation is objective and factual (without drawing conclusions). Although the warning signs are meant to be a guide and not a method of diagnosing a problem, they highlight issues that impact on nursing care. Even if Jane is not having problems with substance use, it appears that her ability to provide safe and competent nursing care is affected by her problems. By reporting the issues now Jane s colleagues will protect their clients and, hopefully, assist Jane in dealing the problems that are affecting her nursing practice. INTERVENTIONS: Registered Nurses and MANAGERS Responsibilities of Registered Nurses The two most prominent barriers to effective intervention by nurses are lack of education regarding the signs of problematic substance use and fear of hurting a colleague s feelings, fear the colleague will lose her/his job or licence, fear of reprisals from other co-workers, and/or fear of rejection from management (Hughes et al., 1994; Daprix, 2003). Although nurses may be concerned about hurting a colleague s feelings, research has shown that some nurses with substance use problems actually feel let down when other nurses and their manager fail to recognize and confront the substance use problem. In some cases, nurses believe that their using behaviour was so obvious that anyone could have identified that the problem was an issue with drugs or alcohol. Following treatment, many nurses also felt they would have sought help earlier if someone had confronted them at an earlier stage (Lillibridge et al., 2002). Many nurses, once they are in recovery, are grateful to those colleagues who were involved their intervention. Nurses do not wish to cause harm and once in recovery are distressed that their actions may have brought harm to their patients (CRNNS, 2006; Clark, 2006). In addition, the fear of hurting a colleague s feelings needs to be considered in light of the fact that, without treatment, addiction may be fatal. Registered nurses need to remember that by reporting a co-worker, they ensure patient safety and open the avenue to assistance for a nurse who has problems with substance use (CRNM, 2002). The fear that a colleague may lose her/his job or licence if s/he is reported is a real one. It is true that some nurses are terminated or placed on leave by their employer, or have their licence to practise nursing suspended or revoked by the College for a period of time. However, that does not necessarily mean that a nurse will lose her/his job or licence forever. Nurses who are committed to recovery can, and do, return to work when they are deemed fit to return to the practice of nursing. More detailed information about what happens when the College becomes aware that a registered nurse may have problems with substances can be found in Appendix B: College s Professional Conduct Process. 12 College of Registered Nurses of Nova Scotia

15 Nurses also need to consider that there are potentially more serious consequences for both patients and the nursing colleagues themselves when a nurse with problematic substance use issues continues to provide nursing care. The following framework provides guidance for nurses confronted with a colleague having difficulties meeting her/his work obligations as a result of potential problematic substance use. It is anticipated that the use of this step-by-step framework will allay nurses fears of rejection by managers and fears of reprisals from co-workers. 1. Identification Review the section entitled Indicators of Problematic Substance Use to determine if the colleague in question is actually exhibiting some of the common indicators of problematic substance use. In cases where there is no concrete evidence of specific incidents, approach the colleague in a supportive and non-judgmental manner and tell her/him that you are concerned because they do not seem like themselves these days. Providing examples of your observations may be enough to get your colleague to acknowledge they have a problem that is affecting their practice. Suggesting that the colleague contact occupational health and/or an Employee Assistance Program can be helpful. Ensure your colleague knows that you will check back with them within a specified timeframe to see how they are doing. Remember, colleagues with problematic substance use issues will likely deny a problem exists and may react negatively to the identification of your concerns. If that is the case, inform your colleague that if the behaviour continues, your professional responsibility will be to speak to the manager. If after speaking with your colleague, you continue to see warning signs, then for the safety of patients and the health of your colleague, you must report the situation to your manager. If you do not wish to discuss their concern personally with your colleague, you should report the issue directly to the manager. 2. Documentation Prior to reporting a situation to your manager, it is essential you accurately document your observations of your colleague s behaviours. This documentation should be objective/factual and contain: times, dates, locations, what occurred, names of witnesses, identification of any patients involved (i.e., patient s initials and hospital numbers), and actions taken. Listing the warning signs and any other unusual activity you have observed will help ensure that all relevant observations are included in the documentation. This documentation does not have to be complicated point form, with the essential information, is all that is necessary. Remember, it is not up to you to diagnose your colleague just document the appropriate information so your manager can address the issues with your colleague. If your manager or the College (if reported to the College) suspects there is a problem with substance use, an assessment for problematic substance use can be arranged in the early stage of the process. In cases of impairment or an immediate threat to patient safety, call the manager first and document immediately after. Remember, your ultimate responsibility rests with the safety of your patients. 3. Reporting When speaking with the manager, focus on specific issues related to your colleague s: 1) job performance; 2) patient care; and 3) interpersonal communication. Do not offer personal opinions or make conclusions Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 13

16 (Hughes & Smith, 1994). Provide the manager with a copy of your documentation and ensure that the manager understands the importance and urgency of the situation. If other documents (e.g., client charts, narcotic control records) can provide further information about the nurse s behaviour (e.g., changes in handwriting or charting practices, inaccuracies in the count of narcotic or other controlled substances) provide the manager with the names and dates of the appropriate documents, the patient s name (if required), and the specific information contained in that document. 4. Follow-up The nurse who documents and reports observations has a responsibility to ensure that the manager has addressed the situation. The nurse may request that the manager follow up with her/him either verbally or in writing. Because of employer/employee confidentiality, the manager will not be able to provide all the details regarding the outcome. However, the manager should be able to assure the reporting nurse(s) that the situation has been addressed and about whether the nurse will continue to work. If no action is taken, continue to document observations and concerns, and address these with the manager again. If there is still no response, be prepared to take the concerns up with the manager s supervisor until appropriate action is taken. The College s Professional Practice Issues Resolution Framework (Appendix C) provides guidance for nurses when addressing issues that, in their opinion, have not been satisfactorily resolved. NOTE: In situations in which a manager is the colleague with problems with substance use, nurses should report to the manager s supervisor or the chief/director of nursing. Responsibilities of Managers The unit manager is responsible and accountable to ensure safe and competent patient care, while at the same time providing a proactive approach to the situation and a constructive way to intervene (Ponech, 2000). It is the manager s responsibility (professionally, ethically and morally) to intervene once staff members have provided her/him with verbal and/or written objective observations related to a concern. If a nurse is obviously impaired while working, the manager must immediately remove the nurse from the work area. Two people should determine whether the nurse is fit to continue working or if s/he should leave the workplace. In the event the nurse s condition warrants immediate removal from the workplace, the nurse should not be permitted to return to work until an investigation into the events of that shift and the nurse s previous practice is completed and the determination is made that s/he is safe to practise. If a nurse is removed from the workplace, the person should be prevented from driving home and arrangements made for someone to drive her/him home. Facilities should have policies and procedures in place that address: 1. Who makes the determination that a nurse should leave the workplace. 2. The arrangements for a nurse to leave (i.e. call a family member or pay for a taxi). 3. How a nurse can access immediate treatment if so requested. Appropriate intervention with an employee who has a problem with substance use has been described as: A structured process by which an individual is confronted with his or her reported behaviours and is asked to seek evaluation of a 14 College of Registered Nurses of Nova Scotia

17 possible substance abuse problem (AACN, 1998). So that the intervention process can be as structured and effective as possible, the manager must (i) collect the relevant data including treatment resources, (ii) document., (iii) present the information to the individual nurse, and (iv) follow up in an appropriate manner. 1. Data collection The collection of information should consist of objective observations of performance, such as: increased potential and/or actual errors or incidents increased absenteeism or tardiness decreased productivity deterioration in co-worker relationships obvious changes to the affected nurse s physical and/or mental health. In addition, even if there is no immediate evidence that a nurse has been diverting narcotics from the workplace, an audit of narcotic records and patient medication records should be undertaken. In all cases where a nurse is suspected of being impaired while at work, a review of the nurse s charting practices is necessary. 2. Documentation Documentation of the issues should consist of: a written record of all reported incidents/observations: names of persons involved, times, dates, what occurred, names of witnesses, and actions taken (information should not include opinions just objective facts). a documented account of unacceptable performance practices and behaviors (see Indicators of Potential or Actual Problematic Substance Use). results of a narcotic audit (if applicable). results of the involved nurse s charting practice audit. 3. Addressing Issues with Nurse Involved Once documentation is complete, the manager should prepare a plan for a meeting with the employee suspected of problematic substance use. This plan should include identifying those who should be present during the interview, as well as the desired outcome of the meeting. In advance of the meeting, the nurse involved should be apprised of the date and purpose of the meeting (i.e., work performance concerns). S/he may choose to have legal or union representatives present. To avoid delays, the manager should be aware of what resources are available for treatment should the nurse decide to do this immediately. Before meeting with the nurse, the manager may also wish to obtain guidance from the facility s legal, human resource, occupational health department, professional practice, addictions prevention and treatment services, or even local law authorities (Ponech, 2000). Most importantly, the manager should follow any related policies in place within her/his facility. The College recommends that facilities have specific written policies and processes for the identification of, reporting of, intervention and follow-up in suspected cases of problematic substance use. If there are no policies in place the manager should, prior to meeting with the nurse, consult with her/his director and with the human resources or risk management department (if available). The manager could also contact the College and speak to a practice consultant or the professional conduct consultant. Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 15

18 Any meeting with a nurse experiencing potential substance use requires a high degree of sensitivity, privacy and confidentiality. A quiet, private setting where there will be little chance of interruption should be selected. During the meeting, the manager should remain calm, kind, supportive and understanding. S/he should present facts to the nurse, not accusations, and focus specifically on documented issues. Comments should be confined to performance issues managers should not attempt to diagnose or label an issue or provide treatment or counselling services. Managers should focus on objective observations, breaches of standards, and the unacceptability of the nurse s behaviour. The manager should not feel compelled to provide information that justifies any observations shared with the nurse (e.g., do not need to give the names of staff members who might have provided written and verbal concerns). If the nurse denies or attempts to rationalize the problem, the manager must be prepared to refocus the conversation back on the issues, all the while expressing concern for the nurse. The manager should listen carefully to the nurse s responses and give her/him the opportunity to voluntarily ask for help. Options should be outlined and a course of action determined that is acceptable to those in attendance at the meeting. Resource options could include treatment and/or referral to an Employee Assistance Program or other services. The manager should have treatment options readily available, in case the nurse wants to seek treatment immediately. The manager should ensure the nurse knows there will be close follow-up, and that s/he can approach the manager if s/he wishes. The nurse should also know that the manager will continue to monitor her/his performance. The nurse may need time to work through her/his issues and weigh personal options. If this is the case, a second meeting may be required. The nurse should be given the opportunity to ask for input/assistance from other sources of her/his own choosing. When meetings are concluded, the manager should document the content discussed at each meeting, as well as the meeting outcomes. Depending on the nature of the reported issues, it may be necessary to report the concerns to the manager s supervisor, the facility s risk management/legal/hr departments and, ultimately, the College. If the facility does not have written policies regarding reporting nurses with experiencing problems with substance use to the College, the manager should contact the College s Professional Conduct Services. The manager should also review any facility policies related to disclosure, particularly to clients and/or family members when there has been diversion of a client s medications. If the nurse fails to respond to the manager s suggestions for treatment and/or assistance, the manager must determine what corrective action could be taken (i.e., suspension from work with or without pay), communicate any possible action to the nurse, and be prepared to take additional action if required. If the nurse is a member of a union the collective agreement will also impact on the appropriate course of action. With respect to financial issues, nurses generally have access to sick benefits (short- and/or long-term) while they are undergoing treatment and recovery. 4. Follow-up If the nurse is not immediately suspended from work the manager should provide her/him with specific criteria, in writing, for performance improvement, timelines for re-evaluation, and information regarding consequences for failure to improve performance. The manager should follow up with any other parties involved with the situation, including the person(s) who initially reported the issue and any involved patients and/or families. The manager must balance the confidentiality of the nurse involved, with the need to provide information to the nurse(s), and any other staff, who may have reported the concerns (Ponech, 2000). 16 College of Registered Nurses of Nova Scotia

19 Case Study: Part 3 Tammy is the new nurse manager on Lucy and Jane s unit. Sally, who was manager for the past 10 years, recently retired. Prior to her retirement, Sally gave Tammy a brief overview of the staff, including their level of experience and issues regarding job performance. Sally indicated that several staff had come to her over the last year with a number of concerns regarding Jane, a nurse who has been on the unit for 12 years. Sally reported that she listened to their concerns but because the staff did not document anything in particular, she never really addressed these concerns with Jane. Sally left Tammy some of her own handwritten notes on the staff s concerns about Jane reported some eight months earlier. A few weeks after Tammy starts her new position, Lucy, one of the experienced nurses raises issues about Jane. She tells Tammy that she is quite concerned because Jane appears to be unwell and she is getting frustrated with Jane s work performance. Lucy tells Tammy that she is tired of following behind Jane to do her work or clean up her mistakes. In addition, Lucy says that Jane has been coming to work late, leaving early and taking frequent breaks many times without telling the staff she is leaving. Lucy says that other staff have told her that Jane has made errors and they have complained about her downright sloppy work. Lucy says that some of the staff suspects Jane is using drugs, but they do not have proof. Lucy says she is concerned because a few months ago, Jane told her that she was taking up to four tablets of Gravol in order to get to sleep. Lucy says that she reported this to the previous manager, but as far as she knows nothing was ever done about it. She says that the other staff told her that they know nothing will be done and, therefore, do not want to get involved As a registered nurse, what is the nurse manager s role in this situation? Does the fact that these issues arose before Tammy arrived affect her responsibility to collect documentation about Jane s past behaviour and performance? As a manager, it is critical that Tammy act on this information. Not only are registered nurse managers responsible to fulfill the general standards for nursing practice, they also have additional standards for which they are responsible. Standard 1.11 (Accountability) states: In addition, the nurse administrator promotes a quality practice environment that supports nurses ability to provide safe, effective and ethical nursing practice. It is evident that the practice environment on Tammy s unit is not safe or effective. Jane has been leaving her patients unattended, making errors and the other staff members have been covering for Jane and/or fixing her mistakes. Jane s behaviour has negatively impacted the quality of the practice environment and, therefore, must be addressed. Tammy realizes that, as the current manager, even though the unit staff has not provided written documentation in the past, she has a responsibility to intervene. She tells Lucy that she is going to investigate the matter immediately and begins by asking Lucy to provide her with documented observations of Jane s performance and behaviour. She then approaches other staff who have worked with both Jane and Lucy and asks them to do the same. Although the unit staff are frustrated by Jane s actions, they still do not want to put anything in writing. The staff is unsure if anything will be done because this has been going on for quite a while and no one ever did anything. Tammy assures them that she is going to immediately address the issues with Jane, but she requires specific information from the staff. She says that it is not fair to Jane to approach her with vague accusations of inappropriate behaviour. continued on next page... Problematic Substance Use in the Workplace: A Resource Guide for Registered Nurses 17

20 continued from page 17 After Tammy explains how she plans to address the matter, the nursing staff is still anxious but relieved that Jane will be supported and that their concerns regarding patient safety will be addressed. How should Tammy approach the staff who previously refused to provide written documentation? How should Tammy approach Jane? Tammy provides the staff who had previously voiced their concerns with the few written notes left by the previous manager, to assist them to recall approximate times and dates. Through their recollections, Tammy is able to pull charts on specific patients to review the Jane s charting and applicable narcotic sheets. Although Tammy cannot force the staff to document, she can interview them about their specific observations and remind them that early identification, early treatment and appropriate referral for treatment leads to the protection of the public, restoration of a nurse s good health, and potentially lead a nurse back to good practice. Tammy should approach Jane in a supportive and caring manner, ask to meet with her and tell her that she can have a union representative with her if she wishes. In many instances, when nurses have problems with substance use, they will immediately admit it to the manager. If Jane does admit that she is having problems with substance use, Tammy should then provide her with resources and assist her to make the appropriate arrangements and/or contacts. If Jane does not admit or does not want to accept help, Tammy needs to remind Jane of her responsibility, as a professional, to remove herself from the workplace ensuring that no harm comes her patients in her care. If Jane does not agree to leave work, Tammy must place her on leave until a full investigation is completed and the facility decides what course of action to take. Tammy should report back to the staff involved and inform them as to whether she will report the matter to the College. If the matter will be reported, Tammy should provide the staff with information about the College s professional conduct process. Case Study: OUTCOME Tammy meets with Jane and, after reviewing the concerns of the staff, Jane admits that she has been diverting and using Demerol injectables for about six months. Jane says that she was afraid of getting caught, but feels relieved because she believes that she is addicted to Demerol. She agrees to undergo treatment, and Tammy assists her to make the necessary arrangements. 18 College of Registered Nurses of Nova Scotia