RECOGNIZING IMPAIRMENT IN THE WORKPLACE 2 HOUR CE (64B ) Intervention Project for Nurses Kathy Whitaker, LMHC

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RECOGNIZING IMPAIRMENT IN THE WORKPLACE 2 HOUR CE (64B9-5.

1 RECOGNIZING IMPAIRMENT IN THE WORKPLACE 2 HOUR CE (64B ) Intervention Project for Nurses Kathy Whitaker, LMHC

OBJECTIVES Upon completion of this course the nurse will: I. Define Impairment/Addiction and identify signs of impairment in the workplace; II. Describe the Mandatory reporting law, Section 464.

2 OBJECTIVES Upon completion of this course the nurse will: I. Define Impairment/Addiction and identify signs of impairment in the workplace; II. Describe the Mandatory reporting law, Section , F.S. and Reporting/Referral Process; III. Recognize the Intervention Project for Nurses (FL. Impaired Practitioner Program for Nurses) role in protecting the public and assisting nurses. Section , F.S.; IV. Acknowledge employer initiatives helpful in promoting safety and provide assistance.

3 PART I. Defining Impairment/Impairing Conditions and Identifying Signs of Impairment in the Workplace

4 WHAT IS IMPAIRMENT? Impairment is characterized by the inability to carry out professional duties and responsibilities in a reasonable manner, consistent with acceptable standards. Impairment is demonstrated by impaired cognitive functioning and memory, altered motor skills, diminished alertness, difficulty making decisions, impaired judgment, and the inability to cope with stressful situations.

Substance Abuse & Workers Among 57.4 million adult binge drinkers, 74.

5 Of the 22.4 million current illicit drug users aged 18 or older in 2013, 15.4 million (68.9 percent) were employed either full or part time Who is at Risk for Impairment? Substance Abuse & Workers Among 57.4 million adult binge drinkers, 74.4% are employed either full or part time U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality

Lost Time Job Turnover & Re-training Healthcare Cost: Cost: Cost: $29,869,440 $15,431,040 $23,030,730

6 This report combines the latest research on employment costs with data from National Survey on Drug Use and Health (NSDUH) to calculate how much substance use in your workforce costs employers annually. Lost Time Job Turnover & Re-training Healthcare Cost: Cost: Cost: $29,869,440 $15,431,040 $23,030,730 Total Estimated Cost: $68,331,210 (300k nurses)

7 Substance Use Disorder in Nursing Substance use disorders are about the same as general public, 10%-15% nationally. ANA reports 6-8 % of nurses use substances to the extent that performance is affected. 67% of nurses reported and/or disciplined by Boards of Nursing throughout the USA are due to substance use/mental health impairment. Potential impairment from SUD has far reaching effects on the identified nurse, patient care and colleagues. National Council of State Board of Nursing

Nurse Personal Risks Specialized knowledge alone does not protect nurses Accessibility Stress Nurses attitude about

D.M., McDonough, J.P, Ellison, J.S., and Fitzhugh, E.C.

Controlled drug misuse by Certified Registered Nurse Anesthetists. Snow, D. and Hughes, T.

8 Nurse Personal Risks Specialized knowledge alone does not protect nurses Accessibility Stress Nurses attitude about addiction Tendency to self-diagnose and self-treat Lack of knowledge/skills to recognize and address impairment Dell, D.M., McDonough, J.P, Ellison, J.S., and Fitzhugh, E.C. (1999) J of the American Association of Nurse Anesthetists; 67(2): Controlled drug misuse by Certified Registered Nurse Anesthetists. Snow, D. and Hughes, T. (2003) J of Addictions Nursing; 14:3, Prevalence of Alcohol and Other Drug Use and Abuse Among Nurses. Trinkoff, A.M. and Storr, C.L. (1998) American J of Public Health; 88: Substance Use among Nurses: Differences between Specialties.

9 Vulnerability to Drug Addiction & Alcoholism Depends on the individual and the interplay of genetic, environmental, and societal factors. The National Institute of Drug Abuse (NIDA) estimates that genetic factors account for percent of a person s vulnerability to addiction. National Institute of Drug Abuse, NIDA Nora D. Volkow, MD, Director NIDA

10 Addiction A primary, chronic disease of the brain, motivation, reward, memory and related circuitry The compulsive use of a substance Even in the case of negative consequences Loss of control Attempts to stop initiate craving and withdrawal

Requires ongoing monitoring Influenced by behavior Tends to worsen if untreated 1. McLellan AT et al. Addiction.

12 Characteristics Drug Dependence Diabetes, Asthma, and Hypertension Well studied Chronic disorder Predictable course Effective treatments Curable NO NO Heritable Requires continued care Requires adherence to treatment Requires ongoing monitoring Influenced by behavior Tends to worsen if untreated 1. McLellan AT et al. Addiction. 2005;100(4): ; 2. McLellan AT et al. JAMA. 2000;284(13): ; 3. McLellan AT. Addiction. 2002;97(3):

13 Substance use disorders, psychiatric illness, psychological problems and physical conditions can all impair a nurse s ability to practice with reasonable skill and safety.

14 How is Impaired Practice Defined? Practice is impaired when the licensee is unable to meet: Requirements of professional code of ethics Standards of practice Because impacted: Physically Emotionally Cognitively Observable unsafe or unprofessional practice

15 Problem Solving Decision making Communication

Vigilance Sustained attention Planning capacity *Prat, G. et al.

16 Hangover can effect Performance Alcoholic hangover Younger licensees risk Binge drinking related to several performance deficits* Memory Vigilance Sustained attention Planning capacity *Prat, G. et al. (2008). Neurocognitive effects of alcohol hangover. Addictive Behaviors 33:

17 Impairing Mental Conditions Depression PTSD Eating Disorders Anxiety Disorders

18 Impacts on Performance Effects of substance use & mental disorders can be observed. Change in performance and behavior Substance use Depression Decrease or inconsistent productivity X X Absenteeism, tardiness X X Increased errors, diminished work quality X X Overly sensitive and/or emotional reactions X X Difficulty learning and remembering X X Confusion and difficulties with decision making X X Withdrawal from co-workers X X Impairing conditions can mimic one another DO NOT TRY TO DIAGNOSE Adapted from ORCAS training online version

19 Identifying Signs of Impaired Practice

20 Attendance/Work Pattern Changes Shows up when not scheduled for shift Takes extended breaks during the shift, sometimes without telling colleagues and without explanation Calls in sick frequently or uses other excuses to miss assigned shifts Pattern of calling in sick before or after a weekend/multiple days off Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

21 Cognitive Performance Forgets how to complete simple tasks Makes inaccurate judgments regarding patient care Exhibits confusion about directions or instructions Unable to accurately communicate specific patient information with team members and/or patients Inability to complete assigned tasks that others do adequately Consistent inability to improve performance or conduct even with training and counseling Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

Interpersonal/Social Performance Exhibits aggression or hostility towards patients and/or coworkers Responds defensively/aggressively when provided performance feedback Crosses professional

22 Interpersonal/Social Performance Exhibits aggression or hostility towards patients and/or coworkers Responds defensively/aggressively when provided performance feedback Crosses professional boundaries through inappropriate sharing of personal information with patients Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

23 Physical Performance Alcohol-like odor on breath Stumbles/staggers while walking Changes in speech pattern (for example; slurred, fast, slow) Fumbles/drops equipment Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

24 Policy Adherence/Drug Diversion Loiters around medicine supply. Insists on performing narcotic counts alone. Reports medication being wasted when the medication was not wasted Reports wasting more of a drug than seems likely Inconsistencies between narcotic records and patient s medical charts for medications administered Has no explanation for medicine withdrawals Waits until alone to open narcotic cabinet and/or to draw up medication Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

25 Policy Adherence/Drug Diversion continued Patients consistently complain that pain is not improving after receiving pain medication Reports lost or wasted medications frequently Fails to ensure observation or co-signing for narcotic wastage Asks others to withdraw narcotics for his/her patients Offers to cover other nurses breaks to administer medications to their patients PRN medications for a patient administered at higher frequency than other shifts Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C., J Nurs Manag Sep;23(6):

26 Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. Cadiz DM, Truxillo DM, O'Neill C. J Nurs Manag Sep;23(6):

27 PART II. Addressing Impairment: Legal and Ethical Responsibilities FL. Mandatory Reporting Law, Section , F.S. Reporting/Referral Process

28 What Is Our Responsibility?

29 Ethical and Legal Responsibilities American Nurses Association Ethical Standards: Code of Ethics for Nurses with Interpretive Statements, Washington, D.C.: American Nurses Publishing, 2015

30 Nursing Code of Ethics Provision 3 The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. (ANA 2015) Patient Protection & Impaired Practice Duty to take action to protect patients Approach individual with impaired practice w/clear supportive manner Extend compassion & caring Assure that the individual with impaired practice receives the necessary help needed for recovery

31 Florida Nurse Practice Act F.S. 464 A legal responsibility to report nurses who have violated the Florida Nurse Practice Act (F.S ) due to the use of drugs and alcohol, or psychiatric or physical problems. Unsafe practice that results in patient harm Pattern of unsafe/incompetent practice Narcotic medication controls are violated Concerns when a colleague may not be fit to perform essential duties

32 Grounds for Disciplinary Actions F.S Mandatory Reporting Law Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition Failing to report to the department any person who the licensee knows is in violation of this part or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant

33 How Do Most Nurses Address Impairment? 1. Action: Ignore Deny Don t ask. Don t tell. Whistle blower 2. Enabling: Willfully or unknowingly make excuses to protect colleague 3. Refer or Report: Reluctant and question self What if I m wrong? What would happen to me? Wait until a crisis occurs

34 Individual Barriers Misconceptions, attitudes and beliefs Personal recovery or family history Previous history with employee Supervisory style Fear of confrontation or resistance Fear of making a mistake Lack of skills or knowledge Lack of confidence to recognize substandard care Tolerant when early warning signs present Chris O Neill, RN, D.Min. and Dave Cadiz, PhD - Oregon Nurses Foundation

35 WHEN YOU SEE SOMETHING SAY SOMETHING AND DOCUMENT WHAT YOU SEE

36 Observe for Concerns, Document and Seek a Witness if Possible Subjective Objective Opinions Emotional reactions Conclusions Theories Descriptions will vary See Hear Feel Taste FACTS Descriptions will not vary

37 Documenting Concerns Objective Facts: Date Time Place Persons Involved Specific Details

38 Recognize that nurses do not seek help on their own. Can t ask for help!

39 Denial Chief Characteristic Most striking and characteristic symptom of impairing conditions An unconscious defense mechanism that allows a person to avoid the full realization of an emotionally painful fact Denial is most likely to occur when reality becomes too threatening to endure. Denial is often manifested in minimization, rationalization, and projection. spouse colleagues friends hospital

40 PART III. IPN (Impaired Practitioner Program for Nurses) role in protecting the public and assisting nurses. Section , F.S.

Some History of the Florida Experience In the 1980 s the Florida Board of Nursing utilized a discipline only track. The Board of Nursing recognized impairment related cases were significant in number.

41 Some History of the Florida Experience In the 1980 s the Florida Board of Nursing utilized a discipline only track. The Board of Nursing recognized impairment related cases were significant in number. About the same time the American Nurses Association called out to the states to pursue alternatives to a discipline only approach for nurses with impairing conditions by; developing programs, disseminating information and conducting research. Florida was the first state to respond to the ANA call. FNA was actively involved in educating and lobbying for the passage of legislation to begin the nation s first Alternative to Discipline Program.

42 Legislation was passed in Florida on October 1, 1983 allowing a new avenue for addressing impairment among licensed nurses providing an alternative to a disciplinary only approach.

43 Changes in Legislation Provided Another Reporting Option: Report Directly to IPN Failing to report to the department any person who the licensee knows is in violation of this part or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant. F.S

44 Options for Making a Referral or Report IPN (Intervention Project for Nurses) Department of Health (DOH) Consumer Complaints > For non- nursing health professionals Call PRN at PRN (8776)

45 Referral and Reporting Options IPN/PRN Disciplinary Alternative Referral Call Consultation/Intake Intervention/Evaluation DOH Discipline Investigation Legal PCP Appropriate Treatment IPN/PRN Monitoring Refusal to Participate/ Failure to progress A/C Formal Hearing Informal Hearing Disciplinary Action

46 Intervention Project for Nurses Mission Statement To ensure public health and safety by providing education, monitoring and support to nurses in the State of Florida Protecting the Public and Assisting Nurses , F.S.

47 How does IPN help to protect the public? Earlier Identification and Swifter Intervention IPN Refrains the Nurse from Practice within 1-3 days (The disciplinary process on average is 6 months before action is taken) Standardized, Comprehensive Fitness to Practice Evaluations Approved Providers and Treatment Programs Comprehensive monitoring for nurses in IPN

48 Making a Referral to IPN

49 IPN Participation Intake Pending Monitoring Completion of Active Monitoring Should a nurse fail to satisfactorily progress, discontinue treatment, and/or fail to comply with program stipulations, the IPN immediately provides this information to the DOH to initiate swift action to ensure the health, safety and welfare of the citizens of Florida. (Florida Statute )

50 Support and Monitoring Network

51 Nurse Support Groups: I no longer feel afraid and alone 148 Nurse Support Groups 82 Facilitators 39 Co- Facilitators

52 Peer Support Network This Photo by Unknown Author is licensed under CC BY-NC-ND Women For Sobriety

53 How Does IPN Determine Fitness To Practice? Criteria: Stability in recovery Support systems Problem-solving ability Cognitive functioning Judgment Ability to cope with stressful situations Decision-making ability in a crisis Negative toxicology

Return to Practice Signed Monitoring Contract is received Treatment is completed, fitness is determined Supervisor obtains a copy of executed contract Practice restrictions are understood by all

54 Return to Practice Signed Monitoring Contract is received Treatment is completed, fitness is determined Supervisor obtains a copy of executed contract Practice restrictions are understood by all parties and often initially include refraining from overtime, floating, multiple employers, agency, home health, hospice employment. When there is a narcotic restriction we encourage a labor exchange buddy be secured. Random Toxicology assignment is set up. A workplace monitor who can offer feedback on performance is established. Engagement in weekly nurse support group

Consistent Attendance at Support/Monitoring Groups Favorable Monitoring

55 Indicators of Satisfactory Progress in Recovery and Safety to Practice Compliance with Monitoring Contract Negative Random Urine Drug Screens Consistent Attendance at Support/Monitoring Groups Favorable Monitoring Reports - Employer - Primary Treatment Provider - Nurse Support Group Facilitator - Self-Report

56 What happens when a nurse fails to comply with program conditions of participation? Should a nurse fail to satisfactorily progress, discontinue treatment, and/or fail to comply with program stipulations, the IPN immediately provides this information to the DOH to initiate swift action to ensure the health, safety and welfare of the citizens of Florida. (Florida Statute 456)

57 PART IV. Employer Initiatives to Promote Safety and Provide Assistance

58 Barriers in the Workplace Inconsistent application of company policy Limited health benefits Unclear collective bargaining agreement Misperception of the Licensing Board s role Staffing shortage Attitudes of managers or co-workers Insufficient training opportunities Mixed messages/inconsistent administrative support Chris O Neill, RN, D.Min. and Dave Cadiz,PhD Oregon Nurses Foundation

59 Psychological Safety in the Workplace Psychological Safety is the perception that it is safe to take interpersonal risks like asking for help, making suggestions, and speaking up Confidence that you will not be embarrassed, rejected, or punished for speaking up Supervisors affect employee psychological safety through their behaviors Feeling safe enhances trust and improves communication Amy C. Edmondson. Managing the risk of learning: Psychological safety in work teams., Harvard University.

Employer Initiatives to Promote Safety and Provide Assistance o Develop clear policies and procedures for addressing impairment in the workplace o Educate nursing staff on issues of impairment in the

60 Employer Initiatives to Promote Safety and Provide Assistance o Develop clear policies and procedures for addressing impairment in the workplace o Educate nursing staff on issues of impairment in the workplace and policy expectations o Provide Supervisor skill training o Promote psychological safety (building trust, open communication) o Promote all employer resources (EAP, Employee Heath etc., IPN)

Takeaways Substance use disorders in nurses is about the same as in the general public (10%-15% nationally) An impairing health condition often results from the misuse or abuse of alcohol or drugs or

sharing your concerns with your supervisor helps you to also share the risk Be familiar with your mandatory reporting responsibilities (F.S. 464.

61 Takeaways Substance use disorders in nurses is about the same as in the general public (10%-15% nationally) An impairing health condition often results from the misuse or abuse of alcohol or drugs or both or due to a mental or physical condition and can affect a colleague s ability to practice with skill and safety Recognize that signs of impairment can be observed and documented Remember that sharing your concerns with your supervisor helps you to also share the risk Be familiar with your mandatory reporting responsibilities (F.S ) to DOH and/or IPN Recognize that referring directly to IPN will fulfill your mandatory reporting obligation; however if the nurse fails to follow through with IPN a report will immediately be forwarded to DOH Understand that supervisor and staff education is crucial for workplace safety Develop clear workplace policies and procedures and communicate to all

62 TOGETHER WE CAN PROTECT PATIENT SAFETY AND OFFER ASSISTANCE AND SUPPORT TO OUR COLLEAGUES.

63 QUESTIONS???? IPN

Alternative to Discipline Programs: The Florida Intervention Project

Alternative to Discipline Programs: The Florida Intervention Project Linda L. Smith, ARNP, MN, M.Div., CAP, CARN-AP Chief Executive Officer Florida Intervention Project Presented for NCSBN-IRE January