Impairment can place everyone in a workplace at risk of injury. First and foremost is the risk to patients, who trust healthcare professionals to provide safe, reliable, and effective care. This course presents information on recognizing the signs and symptoms of emotional-, mental health-, and substance-related workplace impairment. Strategies for intervention and reporting (e.g., how and to whom impairment should be reported) are also outlined, particularly within the context of the Florida Nurse Practice Act. Treatment of impairment, including treatment programs, employer initiatives for impaired nurses, and returning to work, will be discussed. In the state of Florida, the Intervention Project for Nurses (IPN) is the Department of Health's contracted program to address nurse impairment; this program will be discussed in detail.
This course is designed for nurses in Florida who may intervene to prevent or identify impairment in the workplace.
NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.
NetCE designates this continuing education activity for 2 ANCC contact hour(s). NetCE designates this continuing education activity for 2.4 hours for Alabama nurses. AACN Synergy CERP Category B. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
This course fulfills the Florida requirement for 2 hours of education on Recognizing Impairment in the Workplace.
The purpose of this course is to provide nurses with an appreciation of the impact of impairment on the provision of nursing care and on patient health as well as the skills to identify and report instances of workplace impairment.
Upon completion of this course, you should be able to:
- Outline the epidemiology and scope of impairment in the healthcare workplace.
- Discuss unique risk factors for substance abuse in nurses.
- Identify the signs of impairment in the nursing workplace.
- Analyze the process and legal obligations involved in reporting an instance of impairment in the workplace.
- Describe the treatment programs available for nurses who have been impaired in the workplace.
Nancy Campbell, RN, BSN, PHN, received her Bachelor of Science in Nursing degree from California State University, Bakersfield in 1987. She has nursing experience in a variety of clinical settings, including medical/surgical, community health, and preschool health. She was a nurse case manager for a community program supporting teen parents and a public health nurse focusing on communicable disease management. Her primary focus and passion is on direct patient care and patient education. She is presently employed as a registered nurse for the Head Start program in Tulare County, California.
Contributing faculty, Nancy Campbell, RN, BSN, PHN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Jane C. Norman, RN, MSN, CNE, PhD
The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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#31110: Recognizing Impairment in the Workplace: The Florida Requirement
Impairment of a healthcare professional can place everyone in a workplace at risk for injury. First and foremost is the risk to patients, who trust healthcare professionals to provide safe, reliable, and effective care. The ethical duty to not harm patients is a cornerstone of nursing, yet impaired healthcare workers injure patients daily. Another concern is the potential for impaired nurses to harm other professionals in the workplace, either directly or indirectly. Direct harm falls on a spectrum ranging from serious, injury-causing accidents to excessive absenteeism, which puts additional strain on staff. Presenteeism (i.e., reporting for work while impaired) places colleagues in the difficult position of having to work harder as a result of another's impairment, working in a potentially dangerous environment, and facing the dilemma of reporting a coworker, colleague, or friend.
Reporting impairment can be a difficult ethical situation for healthcare professionals, who often cover for impaired colleagues out of friendship or loyalty and who fear that reporting may ruin the nurse's career or their own. The truth is that the circumstances causing impairment have already eroded a nurse's professional abilities to some degree, and in most states, including Florida, good-faith reporters (i.e., those with sincere and honest intentions) are protected from retaliation by whistleblower laws. Conversely, not reporting a known impaired nurse is a violation of the Nurse Practice Act that can lead to disciplinary action by the Florida Board of Nursing.
Injury to patients and coworkers is increasingly likely when a worker is impaired, but impairment also gravely affects the individual nurse, whose health, safety, career, and social and financial standing are at risk if interventions are not undertaken. The American Nurses Association (ANA) definition of impairment describes a broad array of conditions that can interfere with workplace functioning, including mental or physical illness, fatigue, substance abuse, and other personal circumstances that adversely affect job performance . Though fatigue and certain personal circumstances may be more easily resolved, these types of impairment still pose a danger. Fatigue, acute physical illness, and personal issues (e.g., stress, relationship problems) are generally dealt with in a different manner than impairment related to chemical dependence, other psychological disorders, and chronic physical conditions. It should be remembered that alcohol and/or substance abuse is a type of medical and psychological disorder, and helping the nurse obtain treatment so she or he can get healthy and return to work is the ultimate goal of reporting and intervention. Nearly all states, including Florida, now offer nurses found to be impaired at work an alternative to criminal prosecution, the chance to retain their license, and a return to nursing if they agree to enter and participate in an intervention program.
This course presents information on recognizing the signs and symptoms of emotional-, mental health-, and substance-related workplace impairment. Strategies for intervention and reporting (e.g., how and to whom impairment should be reported) are also outlined, particularly within the context of the Florida Nurse Practice Act. Treatment of impairment, including intervention programs, employer initiatives for impaired nurses, and returning to work, will be discussed. In the state of Florida, the Intervention Project for Nurses (IPN) is the Department of Health's contracted program to address nurse impairment; this program will be discussed in detail.
Historically, the rate of alcohol and drug dependency among healthcare professionals was thought to be much higher than in the general public, due to job stress and easy access to pharmaceutical drugs. However, the rate among nurses and physicians is now estimated to be only slightly higher than or equal to the rate found in the general public (10% to 15%) [3,4,5,6,9]. The ANA has reported that approximately 7 out of 10 dependent nurses (or 7% of all nurses) abuse substances to the point at which interference with vocational practice can be expected . Based on these data, up to 300,000 of the 3 million nurses in the United States have alcohol and/or drug use disorders, and job performance may be affected in more than 200,000 nurses . Nurses make up the greatest proportion of healthcare workers in the country; therefore, substance-related impairment among nurses is a major healthcare problem, despite similar rates of abuse and dependency among other healthcare professionals .
One study found that while the rate of drug dependence was similar among female nurses and women in the general population, the rate of prescription drug abuse was much higher (more than double) among nurses; use of street-type drugs (e.g., cocaine, cannabis) was found to be lower in nurses than in the general population . Reasons cited for the higher rates of prescription drug abuse included easier access, familiarity with dosages and effects, and comfort experimenting with drugs commonly prescribed to patients . This phenomenon, referred to as "pharmacological optimism," is based on the engrained belief that pharmaceutical drugs cause profound healing with few to no negative effects, an idea that is established early in some nurses . Aside from alcohol, which is the most commonly abused substance among nurses, one study identified the classes of drugs most often abused, in order of frequency, as amphetamines, opioids, sedatives, tranquilizers, and inhalants. In this study, abuse was defined as prescription drug use without a script, using greater than the prescribed dosage, or using a drug for indications other than those prescribed . In many instances of abuse, drugs were obtained through diversion. Drugs are diverted in several different ways [6,11]:
A physician writes a prescription for the nurse in the absence of a true indication.
The nurse steals scripts and falsifies prescriptions for him- or herself.
A whole dose of an injectable drug ordered for a patient is used by the nurse and replaced with saline, or the nurse retains the correct (drug-filled) syringe and replaces it with another filled with saline.
Partial doses of medications are administered to patients while the nurse saves or uses the remainder.
A nurse applies a skin patch to him- or herself before transferring it to the patient.
A nurse removes syringes or ampules from a sharps waste container to scavenge any remaining drugs.
The nurse has a colleague who, without actually witnessing the disposal, cosigns a record indicating waste while the nurse actually retains or takes the drug dose.
The nurse obtains medications for patients who have not asked for them or who refused them.
The nurse signs out medications for a patient who has been transferred.
All of these examples of diversion techniques have been documented, including cases in which patients have been infected with hepatitis C when a nurse used a syringe of opioid narcotic intended for them before replacing the missing contents with saline and injecting the patient . One study found that 65% of nurses addicted to a pharmaceutical drug were diverting medication from their workplace . Most addicted nurses in this study admitted to treating patients while impaired.
Positive attitudes toward drugs and drug use (i.e., "pharmacological optimism")
Relaxed physician prescribing practices in the facility
Lack of pharmaceutical controls in a facility
Little or no education regarding substance use disorders
Enabling by peers and managers
The prevalence of substance abuse varies by nurse specialty. Critical care, psychiatric, emergency room, and oncology nurses have been found to have the highest rates of substance abuse, but alcohol abuse (five or more drinks per occasion) in particular is a significant problem among oncology nurses [9,19]. Another study found that binge drinking was more common among all nurses than in the general population 35 years of age or older .
Gender is another factor for substance abuse in nursing professions. Male nurses are more likely to abuse substances and are over-represented in treatment programs . However, the majority of RNs (91%) and LPNs (92.5%) in the United States are women; therefore, the vast majority of nurses with substance use disorders are women [9,12]. Studies have shown that men's addiction runs a more acute course, with less pronounced physical and mental effects; men also tend to seek help sooner for the actual addiction. In contrast, women's addiction tends to be prolonged, with a greater mental and physical toll. Women typically seek help for the manifestations of addiction, such as depression, anxiety, and insomnia, which can delay treatment for the root cause .
It is important that nurses have the ability to recognize signs and symptoms of impaired practice and be able to differentiate a pattern of impairment from isolated incidents that may be caused by job stress. Studies have shown that most nurses are not able to accurately identify impairment in the workplace because they have little education on signs and symptoms of impairment in a professional setting and among other professionals [3,17,18]. This is compounded by the fact that some individuals, particularly experienced healthcare providers, may be able to function at a high level while under chemical influence. Failure to identify impairment or a belief that reporting is unnecessary because an individual is able to function normally despite alcohol/drug abuse may result in a failure to document and report suspected impairment, inadvertently enabling the substance abuse . On the other hand, nurses who have the knowledge and confidence to identify impairment are empowered to confront colleagues and report their peers according to employer protocol.
According to the IPN, "impairment is a condition that results from the use of mind/mood altering substances, distorted thought processes found in the psychologically impaired, or a physical condition that prevents the nurse from providing safe patient care. Impairment is characterized by the inability to carry out the professional duties and responsibilities in a reasonable manner consistent with nursing standards" .
It should be remembered that impaired practice is not strictly related to substance abuse disorders. Common mental health disorders, such as depression and anxiety, have the potential to interfere with nurses' ability to provide adequate patient care . In a meta-analysis of research related to the impact of mental disorders on the work performance of nurses and other healthcare professionals, strong evidence was found to support a relationship between mental disorders and general errors, medication errors, near errors, impaired patient safety, and decreased patient satisfaction . This is a particular concern given the fact that nurses are at greater risk for certain mental health issues (e.g., depression) than the general public .
Physical disability may also impede nurses' performance, and steps should be taken to create disability inclusive workplaces . Some nurses may be hesitant to disclose disabilities or known limitations for fear of losing their jobs . Physical limitations are not grounds for dismissal, and failure to disclose poses a greater safety risk than working with healthcare professionals with known disabilities.
Signs of impairment related to substance abuse among healthcare professionals fall into three general categories: job performance issues, emotional and mental status, and workplace drug diversion . Impairment specifically related to substance abuse may present differently in nurses than in the general public. Signs of impairment related to job performance include [7,8,13,22]:
An excessive number of mistakes at work (e.g., frequent medication errors, errors of judgment in patient care)
"Job shrinkage" (i.e., the nurse progressively performs the minimal amount of work necessary)
Increased difficulty meeting deadlines or adhering to schedules
Frequent or unexplained disappearances
Implausible and/or elaborate excuses for unusual behavior
Dishonesty over trivial matters
Illegible or sloppy charting
Tremors or shaking
Extended breaks or lunch hours
Excessive absence due to alleged illness, particularly following scheduled days off
Last-minute requests for time off
Absence without notice
Smell of alcohol or cannabis
Excessive use of breath mints, chewing gum, mouthwash, or perfume
Inappropriate or uncharacteristic responses to criticism (e.g., crying, uncontrolled anger, snapping at or arguing with colleagues)
Emotional lability (e.g., becoming uncommonly gregarious or quiet, withdrawn, or irritable; has recurrent mood swings and is unpredictable)
Reduced alertness (e.g., forgetfulness, preoccupation, appearing dazed and confused, slow reaction time)
Increasing isolation from coworkers (e.g., avoiding informal staff gatherings, eating or taking breaks alone, requesting transfer to another shift)
Increased and uncharacteristic problem with authority
Change in dress and/or appearance
Volunteering to work with patients who receive regular or large amounts of pain medication
Consistently volunteering to be the medication administrator
Often signing out more controlled drugs than coworkers
Failing to obtain co-signatures
Frequently reporting medication spills or other waste
Reports reflecting excessive use of pain medications on patients
Discrepancies in end-of-shift medication counts
Evidence of tampering with vials, other drug containers, or medication counts
Waiting until alone to open the narcotics box or cabinet, or disappearing after opening it
An increase in patients' complaints of unrelieved pain
Defensiveness when questioned about medication errors
Consistently coming to work early and staying late
Nurse supervisors and managers should maintain an active role in identifying impairment in the workplace by refusing to allow personal manipulation by another nurse or to fear confronting a nurse if patient safety is in jeopardy. It is important to reduce or change a nurse's role or patient assignment and not accept excuses for or ignore poor performance . Several tools have been developed to assess nurses' job performance and fitness for work [24,25]. These measures may be completed by supervisors or individual nurses (i.e., self-report). One such tool is the Common Risky Behaviors Checklist, which assesses five dimensions: absence/tardiness, cognitive impairment, unprofessional communication/boundaries, physical impairment, and drug diversion. A copy of the checklist is available online at https://www.ncsbn.org/ChrisONeil_Checklist.pdf.
Florida law requires that a Board-licensed nurse make a good faith report of another individual's known workplace impairment, whether the situation is acute or there is growing suspicion. But, reporting a colleague is a decision with which many nurses struggle . Experienced, older nurses are more likely to report impairment because they have likely witnessed the negative effects in coworkers at some point; younger and less experienced nurses are less likely to report. Many professionals choose to ignore the problem because they think someone else will or is already handling the situation [1,3]. One study identified several factors that contribute to failure to report by coworkers, including feeling like a "tattle-tale," fear of revenge or retaliation, fear the colleague might react in a violent manner, not wanting to be responsible for jeopardizing a colleague's job, not being confident enough in one's own observations or instincts to confront a colleague, not being an expert in chemical dependence, and believing the intervention would be better dealt with by an expert . Although these concerns may be valid, nursing is a profession that holds patient safety and healing as the highest duty—and not one of these concerns seems related to protecting patients. Furthermore, few of the reasons for non-reporting show any regard for helping a coworker to heal. Nursing is about action, and there is no excuse for failing to act.
Reporting known impairment in Florida is mandatory, not optional. Failure to report an impaired individual who is practicing medicine can lead to disciplinary action by the Board of Nursing. The Florida Statutes Chapter 464.018 Disciplinary Actions defines nursing impairment and describes the conditions and actions an impaired nurse will face. The section states that the following constitutes grounds for disciplinary action or denial of a license :
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. In enforcing this paragraph, the department shall have, upon a finding of the State Surgeon General or the State Surgeon General's designee that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such order, the department's order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public…A nurse affected by the provisions of this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.
The Florida Statutes Chapter 464.018 Disciplinary Actions also contains the mandatory reporting law. The following act constitutes grounds for denial of a license or disciplinary action :
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.
Nurses should be familiar with their organization's policies and procedures for reporting employee substance abuse or other impairment and those regarding assistance programs . When aware of the resources available to an impaired nurse, including the process, programs, and benefits of employee assistance programs or alternative-to-discipline programs, nurses are better prepared and more likely to report impairment. In 1983, the Florida legislature established the IPN as a contact point for nursing impairment reporting, as a treatment and rehabilitation facilitator, and as a monitoring program for impaired nurses within the state . Florida nurses are required to report suspected impaired practice to the IPN and/or the Florida Department of Health . Reporting to either of these entities fulfills the mandatory reporting obligation. With the knowledge that recovery, nonpunitive rehabilitation, and returning to work are the goals of such programs, nurses should feel confident that their colleagues will receive the help they need to overcome their impairment . In the long-term, the report will be beneficial to the impaired nurse, and in the short-term, patients are being protected from harm.
Before making a report, documenting changes in the suspected nurses' behavior and work performance is recommended . The signs and symptoms listed in the previous section of this course are a good starting point. Taking note of specific actions or behaviors will help when making the report and/or confronting a colleague or supervisee.
In the past, professional organizations recommended confronting the impaired individual directly, but this strategy was found to be unrealistic and is no longer endorsed [2,3,16,22]. The ANA Code of Ethics no longer recommends confronting colleagues as the initial course of action before notifying a supervisor . The 2015 ANA Code of Ethics states that "the nurse's duty is to take action to protect patients and to ensure that the impaired individual receives assistance. This process begins with consulting supervisory personnel, followed by approaching the individual in a clear and supportive manner and by helping the individual access appropriate resources" . The Code further states that "nurses must follow policies of the employing organization, guidelines outlined by the profession, and relevant laws to assist colleagues whose job performance may be adversely affected by mental or physical illness, fatigue, substance abuse, or personal circumstances" . The Florida Nurse Practice Act clearly states that the IPN or the Department of Health must be notified, but does not specify how an intervention must proceed .
Some sources suggest that the best outcomes are achieved when a professional interventionist or personnel trained in intervention confronts the individual . Many facilities have employee assistance or human resources personnel who are trained to intervene. The IPN offers intervention training .
The ANA Code of Ethics also provides the following additional advice regarding intervening in cases of suspected workplace impairment :
The nurse should extend compassion and caring to colleagues throughout the processes of identification, remediation, and recovery.
Care must also be taken in identifying impairment in one's own practice and in seeking immediate assistance.
In instances of impaired practice, nurses within all professional relationships should advocate for appropriate assistance, treatment, and access to fair institutional and legal processes. Advocacy includes supporting the return to practice of individuals who have sought assistance and, after recovery, are ready to resume professional duties.
If impaired practice poses a threat or danger to patients, self, or others, regardless of whether the individual has sought help, a nurse must report the practice to persons authorized to address the problem.
Nurses who report those whose job performance creates risk should be protected from retaliation or other negative consequences.
If workplace policies for the protection of impaired nurses do not exist or are inappropriate—that is, they deny the nurse who is reported access to due legal process or they demand resignation— nurses may obtain guidance from professional associations, state peer assistance programs, employee assistance programs, or similar resources.
When a nurse is reported to either the IPN or the Department of Health, the referral triggers a consultation with the reporter and/or the employer of the impaired nurse . This is followed by an intervention and evaluation. The intervention typically occurs one to three days after a report (whereas a standard disciplinary process typically takes 9 to 12 months to remove a nurse from practice) . If a nurse self-reports to the IPN, the intake and evaluation process begins immediately. In Florida, the IPN is charged with accepting reports, evaluating referrals, determining the proper course of action, monitoring the nurse's progress in treatment, and case managing all individuals returning to work . The IPN program objectives are to :
Ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice due to the use of drugs, including alcohol, and/or psychiatric, psychological, or physical condition
Require the nurse to withdraw from practice immediately, and until such time that the IPN is assured that he/she is able to safely return to the practice of nursing
Facilitate early intervention, thereby decreasing the time between the nurse's acknowledgment of the problem and his/her entry into a recovery program
Provide a program for affected nurses to be rehabilitated in a therapeutic, non-punitive, and confidential process
Provide an opportunity for retention of nurses within the nursing profession
Provide a cost-effective alternative to the traditional disciplinary process
Develop a statewide resource network for referring nurses to appropriate services
Provide confidential consultations for nurse managers
Although the IPN assesses referrals to the program to decide the best course of action for the individual, the program does not actually provide treatment for addiction or other diseases/disorders. Rather, the IPN directs individuals to approved treatment programs and providers . Additional services provided by the IPN include advocacy for participants; tracking meeting attendance and discussing recovery progress with group facilitators; comprehensive monitoring of nurses following discharge from treatment; providing random drug screening of participants and detecting relapse; and reporting compliance issues to the proper authority [1,23]. If at any time during the process the nurse refuses to participate in the program or fails to comply with program guidelines, including after returning to work, she or he is referred to the Department of Health for discipline, which entails investigation, hearings, and disciplinary action.
Following completion of approved treatment, the IPN determines if nurses in the program are ready to return to practice based on several criteria, including the individual's stability in recovery, cognitive functioning, decision-making/problem-solving ability, use of good judgment, ability to deal with stressful situations, and development of a support system . A signed advocacy contract and completed relapse prevention workbook must also be submitted. Stability in recovery is crucial and is indicated by advocacy contract compliance, consistently negative random urine drug screens, regular attendance at support and monitoring groups, and favorable monitoring reports . Progress reports are generated by treatment providers, nurse support group facilitators, and by the nurses in recovery (i.e., self-reports).
The support system for nurses returning to work includes a weekly support group for ongoing self-care and relapse prevention. A coworker is also established as a workplace monitor to provide feedback to the IPN on the nurse's job performance . If a nurse was referred to the IPN due to pharmaceutical use or diversion, it is recommended that the nurse be assigned a labor exchange colleague assigned to handle patient medication duties. Other restrictions for these individuals may include no overtime or floating; no multiple employers; and no agency, hospice, or home care employment .
The Florida Board of Nursing allows nurses two opportunities to return to work after referral for diversion of drugs or narcotics . A nurse will not have their license reinstated after a third violation of drug diversion for sale or personal use.
Employers should have clear policies and procedures for fostering and maintaining a drug- and alcohol-free workplace and ensuring that nurses are fit to practice. When system deficiencies are found to exist, these should be remedied. Employees benefit from a sense that policies are enforced equally and without exception; otherwise, uncertainty will exist as to whether poor behavior is overlooked or ignored if an employee is well liked or has perceived seniority. The National Council of State Boards of Nursing (NCSBN) recommends several employer policies to promote safety, including drug testing before employment, testing when there is suspicion of drug use, and conducting regular fitness-to-practice evaluations .
All employees should be familiar with and abide by their facility's policies, guidelines, and procedures. The NCSBN recommends that nurses be familiar with procedures (internal and external) related to how to document concerns, how and when to report impairment, return to practice after treatment, and relapse management . Nurses should also be provided with information about employee assistance programs (if applicable), including a clear understanding of the confidentiality of such programs.
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