Study Points

Recognizing Impairment in the Workplace: The Florida Requirement

Course #31111 - $15 • 2 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. The rate of alcohol and drug dependency among nurses and physicians is estimated to be slightly higher than or equal to the rate found in the general public (10% to 15%).

    SCOPE OF THE PROBLEM

    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 15% of all nurses abuse substances to the point at which interference with vocational practice can be expected [13]. 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 [6]. 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 [9].

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  2. Use of street-type drugs (e.g., cocaine, cannabis) is higher in nurses than in the general population.

    SCOPE OF THE PROBLEM

    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 [5]. 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 [6]. This phenomenon, referred to as "pharmacologic optimism," is based on the ingrained belief that pharmaceutical drugs cause profound healing with few to no negative effects, an idea that is established early in some nurses [9]. 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 [9]. 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.

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  3. A positive attitude toward drugs and drug use (i.e., "pharmacologic optimism") is a unique risk factor for substance use in nurses.

    UNIQUE RISK FACTORS

    In addition to the common risk factors for substance abuse in all individuals, several unique risk factors have been identified for nurses, including [9,15]:

    • Positive attitudes toward drugs and drug use (i.e., "pharmacologic 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

    • Role strain

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  4. Male nurses are more likely than female nurses to abuse substances and are over-represented in treatment programs.

    UNIQUE RISK FACTORS

    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 [9]. However, the majority of RNs (90.9%) and LPNs (92.4%) 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 [9].

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  5. Impaired nursing practice is defined as isolated incidents that may be caused by job stress.

    IDENTIFYING IMPAIRMENT IN THE WORKPLACE

    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 [3]. 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.

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  6. Frequently reporting medication spills or other waste may be a sign that a healthcare professional is diverting drugs for personal use.

    IDENTIFYING IMPAIRMENT IN THE WORKPLACE

    Signs that a healthcare professional is diverting drugs for personal use include [7,8,22]:

    • 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

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  7. Experienced, older nurses are more likely to report impairment because they have likely witnessed the negative effects in coworkers at some point.

    REPORTING COLLEAGUES AND MANDATORY REPORTING LAW

    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 [3]. 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 [3]. 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.

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  8. Reporting suspected impaired practice to Florida's Intervention Project for Nurses does not fulfill the mandatory reporting obligation.

    REPORTING COLLEAGUES AND MANDATORY REPORTING LAW

    Nurses should be familiar with their organization's policies and procedures for reporting employee substance abuse or other impairment and those regarding assistance programs [16]. 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 [20]. Florida nurses are required to report suspected impaired practice to the IPN and/or the Florida Department of Health [21]. 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 [3]. In the long-term, the report will be beneficial to the impaired nurse, and in the short-term, patients are being protected from harm.

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  9. The American Nurses Association Code of Ethics recommends confronting potentially impaired colleagues as the initial course of action, before notifying a supervisor.

    REPORTING COLLEAGUES AND MANDATORY REPORTING LAW

    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 [3]. 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" [2]. 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" [2]. 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 [21].

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  10. When a nurse is reported for suspected impairment at work, intervention typically occurs within one to three days.

    TREATMENT PROGRAMS

    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 [1]. 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) [1]. 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 [23]. The IPN program objectives are to [23]:

    • 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, psychologic, 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

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.