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Substance Use Disorder (SUD) �in Nursing: �Awareness and Prevention: �Part 2

These educational materials were developed through a collaboration with the Minnesota State Board of Nursing, the University of Minnesota School of Nursing, the Nurse Peer Support Network, and MHealth. Dina Stewart, DNP, APRN, PMHNP-BC created the learning materials and has given permission for the University of Minnesota School of Nursing to disseminate the materials to schools of nursing in Minnesota.

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Objectives

Describe the risk factors and protective factors of substance use disorder for nurses

Clarify personal values related to substance use disorder in order to address the stigmatization of nurses with substance use disorder

Outline the professional, personal and legal consequences for nurses with substance use disorder

Describe the signs of an impaired nurse in the workplace

Identify evidence of diversion in order to have awareness in a clinical setting

Identify approaches to engaging peers and managers regarding substance use disorder related concerns

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Signs of an Impaired Nurse – Behavioral Signs

(NCBSN, p.60, 2011)

Attendance issues
Frequent breaks
Slurred speech
Errors in judgement
Self Isolation
Irritability

The readings are thorough in the description of signs of an impaired nurse. Things to keep in mind are that impairment pertains not to just substance use. There could be impairment related to other mental or physical illness.

Also, there is a spectrum of impairment that ranges from obvious intoxication where a nurse colleague is clearly unable to function – to very subtle signs that accumulate to form a concerning pattern over time.

When considering these signs, it is important to compare to a known baseline for what the nurse’s usual work performance is like.

Behavioral observations in co-workers include:

Frequent tardiness & excessive absenteeism – showing up late, or not showing up at all are signs that substance use is impacting an individual. They may either be under the influence when they are supposed to start work, or they may be experiencing a hangover or coming down from a recent substance use episode.

Frequent breaks may indicate that a peer is sneaking off to use.

Avoidance of Supervision. For example, a nurse who makes her/himself scarce whenever a manager or supervisor is nearby. She/he may make excuses in order to avoid receiving any feedback.

Slurred Speech – this is a fairly obvious sign of impairment. Any number of substance could be contributing.

Errors in Judgment – observing poor nursing care and documentation that appears non-sensical or sub-par is a sign that there is some impairment.

Self-Isolation – similar to avoiding supervision, a nurse who avoids contact with any other staff should raise a red flag.

Irritability – this is another thing to compare to someone’s baseline.

With all these signs, it is important to consider context and allow people the grace to possibly be having a bad day. There is a spectrum of signs for concern and there are gray areas. It is important as the thought enters your mind that something isn’t right for a peer, to examine it completely within the context. If there is concern about a peer where there is obvious concern for immediate harm to the patients under their care – that is a different situation than noticing a pattern of changes in a peer over time.

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Signs of an Impaired Nurse – Physical Signs

(NCBSN, p.60, 2011)

Changes in appearance
Reddened eyes
Odor of alcohol
Drowsiness
Hyperactivity
Wearing long sleeves in a warm environment
Excessive sweating
Clumsiness

In addition to behavioral signs, there may be some physical signs that a peer is impaired. These may vary depending on the nurse’s drug of choice. Someone who uses alcohol will have different physical signs of impairment than a person who is using opioids.

Physical signs include – and again, we might be looking as changes from a baseline.

Changes in appearance – rapidly losing weight or gaining weight, not engaging in self care or grooming as well as they had in the past.

Reddened eyes – indicates recent substance use

Odor of alcohol

Drowsiness – could be related to recent opioid use or alcohol use

Hyperactivity – related to stimulant use

Wearing long sleeves in a warm environment – this is to cover signs of IV drug use

Excessive sweating, hand tremors or clumsiness – this might be due to withdrawal after a period of abstinence.

As previously noted, these physical signs are not entirely black and white. In the gray areas, you need to note what seems odd and be able to recognize patterns.

Refer to the assigned readings for a comprehensive list of signs of impairment.

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Signs of Diversion

Volunteer to administer medications
Volunteer to work overtime or extra shifts
Patients complaint of ineffective pain relief
Discrepancies in medication counts
High amounts of opioid waste

The nurse who is diverting has often been described as “super nurse” because of the eagerness to appear helpful. Volunteering to pass meds or work extra. The extra shifts may be to have more access to diversion, or it may be to make more money to fund their substance need.

Some signs that a nurse is diverting medications includes:

They Volunteer to administer medications – having more access to passing medications provides more opportunity to divert.

Volunteers to work extra shifts or overtime – again, more access to the drugs, more opportunity.

Patient complaints of ineffective pain relief – This is due to the nurse either delivering a partial dose of pain medication or administering a placebo.

Discrepancies in medication counts – the count is short because the nurse took more than what was documented.

High amounts of opioid waste.

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Reporting a Nurse Colleague must be Based on the Code of Ethics for Nurses

ANA Code of Ethics (2015: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” (Provision 3)

“Nurses must understand that if nurses with a substance use disorder are not helped they are in danger of harming patients, the facility’s reputation, the nursing profession and themselves” (NCSBN, 2011, p. 54).

When Suspicions Occur…

State nurse practice acts may have rules and regulations mandating that nurses with knowledge of another nurse practicing while impaired is required to report it.

It is important to know what the signs for impairment and diversion. Now that you have a grasp on that, you need to consider what to do when you identify concern that a nurse colleague is working while impaired or diverting medication.

Intervening for a colleague is founded on the Code of Ethics for Nurses premise of “Do no harm” to patients. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. (pause) Nurses must understand that if nurses with a substance use disorder are not helped they are in danger of harming patients, the facility’s reputation, the nursing profession and themselves

NOT intervening puts patient safety at risk – may also put life of the nurse with SUD in jeopardy as well – substance use can be life threatening.

In Minnesota, the nurse practice act mandates that any nurse with knowledge of another nurse practicing while impaired is required to officially report it. Be sure to know the rules and regulations of your state’s nurse practice act.

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Only about 1 in 3 nurses who suspect a peer is impaired report it to a supervisor

(Kunyk & Austin, 2011)

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When Suspicions Occur…

SAY SOMETHING

DO NOT DO NOTHING

Health professionals cite their reasons for not reporting a suspected peer is believing someone else would do it, or that nothing would happen as a result of the report (DesRoches et al., 2010).

Other reasons include friendship or loyalty, guilt, or fear of being perceived as a “snitch” (Dunn, 2005)

You may not feel comfortable approaching an individual you suspect is impaired, however, you should be prepared to bring concerns to a manager or supervisor.

The rationale for saying something or doing something when you suspect a peer is impaired is two-fold:

First, you need to protect the people under that nurse’s care. Second, the impaired nurse colleague needs to be advised to seek treatment.

Firing of nurses for impairment does not address their need for getting treatment for the chronic disease of SUD, it simply moves them from one place of practice to another.

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Intervening for a Nurse Colleague

WHAT to inform the Nurse Manager:

Deviation of job performance from normal baseline
Personality changes / emotional lability
Alterations of mental status
Possible / probable diversion of drugs from the workplace (miscounts, poor patient pain control, etc.)

When Suspicions Occur…

What do you do if you observed some concerning signs in a colleague?

There are many factors to consider when concerned about a colleague. You may feel comfortable addressing it directly with the individual, however, in all cases, it is appropriate to inform the colleague’s manager or supervisor.

Once you are aware of the possibility that a colleague may have a substance use issue, the first thing you should do is document what you are observing that leads you to suspect them. It could be observations or suspicions related to poor practice, observations of their physical appearance or behavior. It could also be poor, inadequate documentation.

BE SPECIFIC! – Note the date, the shift, what exactly has been observed, specific details regarding actual incidents. Sometimes they will go back into the record and try to make changes to charting – if it is sloppy or incomplete); note changes to the personality or cognitive status of the nurse

As soon as you become concerned or observe a major variation from the baseline, that is when to start sharing your concern. Don’t wait. It’s the nurse manager’s responsibility to look for patterns of behavior in the employee, and you are providing evidence by documenting your observations.

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Approaches for engaging peers and managers

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Hey, are you feeling okay?

(concerned tone) You actually look a little tired. Before your break you were seemed so jittery. It was like you were bouncing out of your chair. And now you are super mellow.

It is a big change from how you were before break to how you are now.

If I’m noticing it, then others are too. Over the past few weeks, it seems you are not yourself. You usually look put together and it seems like something is off.

I’m feeling great, why? What’s up?

Well I feel fine. You don’t need to make a big deal out of it.

So what are you saying?

I don’t know what to say…

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Alternative-to-Discipline Programs

Alternative programs were developed to offer rehabilitation (especially monitoring) prior to or in lieu of discipline from state Boards of Nursing (BON)
Alternative programs offer some nurses the option to bypass BON investigation and disciplinary hearings
Nearly every state in U.S. has an alternative program (In Minnesota – Health Professionals Services Program [HPSP])

An important player in the assessment, treatment, and post-treatment monitoring for nurses with SUD is the state’s alternative-to-discipline program (nearly every state has one). Again, if your future practice takes you to other states, you are highly encouraged to learn about what alternative to discipline programs are available there.

They were developed to offer rehabilitation (especially monitoring) prior to or in lieu of discipline from state Boards of Nursing (BON)

Alternative programs offer some nurses the option to bypass BON investigation and disciplinary hearings. The Minnesota program is called the health professionals services program or HPSP.

HPSP is a large agency monitoring members of numerous healthcare disciplines – nursing, social work, department of health, veterinary medicine, who have been or are being treated or monitored for a SUD or other psychiatric illness that may involve possible cognitive impairment or decision making that jeopardizes patient safety. In Minnesota, reporting a peer to the HPSP fulfills the mandated reporting obligation outlined in the Nurse Practice Act.

Nurses may refer themselves, or there is an option to anonymously refer an individual.

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Health Professionals Services Program (HPSP) Minnesota’s Alternative-to-Discipline Program:

Mission: Minnesota's Health Professionals Services Program protects the public by providing monitoring services to regulated health care professionals whose illnesses may impact their ability to practice safely.

https://mn.gov/boards/hpsp/

The mission of HPSP, like that of the state BON is to protect the public. The BON does this through regulation while HPSP does this by providing monitoring services to the various healthcare professions in the state when a member suffers an illness (SUD, psychiatric, cognitive impairment) that impairs practice.

HPSP has Quick entry into practice monitoring – as soon as the report is made, there can be action taken to ensure the safety of the nurses practice.

Studies show that reports to boards of nursing are much less efficient at removing an impaired nurse from practice. Due to the bureaucratic nature of discipline for the license,

An additional benefit of the HPSP is that they will do all the work needed to ensure that a nurse is safe to work. A nurse enrolled in it is closely monitored for adherence to the treatment plan for maintaining sobriety. They are assigned a case manager with whom they meet regularly. The HPSP involves the nurse’s employer to ensure that the nurse is working within the scope that the HSPS has determined appropriate for the nurse. If the nurse deviates from the HPSP treatment plan, then a disciplinary process starts with the Board of Nursing. Review the HPSP website.

The HPSP promotes rehabilitation and recovery as opposed to discipline and punishment that comes with BON disciplinary hearings. After completion of HPSP, many nurses identify the accountability provided because of close monitoring helped with early recovery and sobriety

Nurses report they are better nurses after treatment and while practicing recovery.

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Disciplinary Consequences for Nurses with SUD

The board can dismiss the complaint without taking action
The board can refer a nurse to HPSP
The board can take disciplinary action(s):

Deny license
Revoke license
Suspend license
Impose limitations on practice
Impose civil penalty
Order unremunerated services
Censure or reprimand
Other action, as justified

There is evidence that suggests alternative to discipline programs are good for nurses with SUD and good for the nursing profession. So it is recommended as the first line for reporting a concerned nurse. The other reporting option is to go directly to the state board of nursing. When an impaired nurse is reported directly to the board of nursing there are a number of outcomes that can occur:

The board can dismiss the complaint without taking action. There is no public record of a dismissal. A complaint alleging Substance Use Disorder might be dismissed if there is no evidence to substantiate the report of SUD or the nurse has SUD but it has been well-managed for an extended period of time.

The Board can refer a nurse to the HPSP. This is similar to a dismissal in that there is no public record of the Board’s action but it differs in that the nurse is expected to contact the HPSP, enter into a participation agreement and monitoring plan and comply with the terms of the agreement. If the nurse fails to do so, the HPSP will report back to the Board and the Board will re-evaluate the situation.

The Board can take a disciplinary action. Most disciplinary actions are taken with the agreement of the nurse and are documented in a Stipulation and Consent Order. By law, these documents are public. (Read the ppt).

The benefits to avoiding discipline with the board of nursing it remains confidential. It becomes public record when disciplinary action occurs. You can go to the Minnesota board of nursing website right now a get a list of licensees who have had licenses suspended or revoked.

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Recovery

Definition: An active, ongoing process for a person with a substance use disorder to:

Admit having a substance use disorder
Abstain from drugs/alcohol
Acceptance of SUD
Improve health through the integration of body, mind, and spirit -- (Betty Ford Institute Consensus Panel, 2007).

HPSP and BON involvement are only a few of the strategies needed by a nurse after SUD treatment.

Nurses who have engaged in treatment for substance use disorder and continue to abstain from substance use define this as recovery. Living in “Recovery” is recommended and is a multifaceted process, as defined on the slide by the Betty Ford Institute Consensus Panel:

Learning to accept self as a person (and as a nurse) with a substance use disorder. This involves trying to overcome shame, guilt, fear, stigma by working a strong recovery);
Avoiding drug of choice and other addictive substances;
Working diligently at taking care of self (health) Mind / body and spirit, by using various tools: such as 12-step program, seeing therapists/counselors, attending meetings, recognizing need for and setting boundaries (with family and at work). Nurses in recovery recognize that they are active participants in their recovery.

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Nurses Peer Support Network:

Mission:

Meaningful peer support for nurses with substance use disorder in a safe environment with the purpose of giving hope and healing the individual nurse
Education and outreach about substance use disorder in nursing to promote safety to the public

Vision: All nurses in Minnesota will have access to a community-based peer support for substance use disorder

http://npsnetwork-mn.org/

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References

American Nurses Association. (2015). Code of ethics for nurses: With Interpretive statements. Silver Springs, MD: NurseBooks.org:

Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33, 221-228. doi:10.1016/j.jsat.2007.06.001

DesRoches, C. M., Rao, S. R., Fromson, J. A., Birnbaum, R. J., Iezzoni, L., Vogeli, C., & Campbell, E. G. (2010). Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA, 304(2), 187-193.

Dunn, D. (2005). Substance abuse among nurses: Defining the issue. AORN Journal, 82, 573-596.

Health Professionals Services Program. (2016). State of Minnesota: Health Professionals Services Program (HPSP). Retrieved from http://mn.gov/health-licensing-boards/hpsp/

NCSBN. (2011). Substance use disorder in nursing: A resource and guidelines for alternative and disciplinary monitoring programs. Chicago: NCSBN.

Monroe, T., & Kenaga, H. (2010). Don't ask don't tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 504-509.