Substance Abuse by Nurses
Finance & Econ
dunn_3.pdf
Home Study Program NOVEMBER 2005, VOL 82, NO 5
Substance abuse among nurses— Intercession and intervention
he article “Substance abuse among nurses—Intercession and interven- tion” is the basis for this AORN Journal independent study. The behav- ioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for
Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who suc-
cessfully completes this study will receive a certificate of completion. The deadline for submitting this study is Nov 30, 2008.
Complete the examination answer sheet and learner evaluation found on pages 803-804 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program
2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.
You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES After reading and studying the article on substance abuse among nurses, nurs-
es will be able to
1. discuss how a nurse should report a colleague suspected of substance abuse,
2. explain the nurse manager’s role in counseling and intercession with a sub- stance abusing employee,
3. identify outcome options for an intercession with a nurse suspected of sub- stance abuse,
4. identify return-to-work issues in regard to keeping the suspected nurse in the workforce, and
5. explain how staff member acceptance can enhance treatment program success.
Home Study Program
This program meets criteria for CNOR and CRNFA recertifica- tion, as well as other continuing education requirements.
A minimum score of 70% on the multiple- choice examination is necessary to earn 4.7 contact hours for this independent study.
Purpose/Goal: To educate perioperative nurses about the problem of substance abuse among nurses.
T
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Debra Dunn, RN
Editor’s note: This is the second article in a two-part series on substance abuse among nurses. Part I was published in the October 2005 issue of the AORN Journal.
Drug and alcohol addictions areprimary, chronic, progressive,and often fatal health problems, but many nurses choose to remain silent about a colleague who may have a substance abuse problem. It is not easy to report a coworker because of friendship, loyalty, fear of being a hyp- ocrite, guilt, or fear of jeopardizing a colleague’s license to practice.
It is helpful to remember, however, that the reason for reporting inappro- priate nursing behavior is to protect patients, not punish the caregiver. It is the responsibility of the person who discovers a problem to report this situ- ation via appropriate channels. This article discusses how to confront and report a nurse suspected of having a substance abuse problem and the nurse manager ’s role in counseling and intercession. Available remedial programs, return-to-work issues, and the continuing need for education regarding substance abuse among nurses also are presented.
REPORTING A PEER If a nurse suspects that a colleague
has a substance abuse problem, it is best that he or she first talk to the nurse about the situation discreetly and in a nonconfrontational manner because there may be a reasonable explanation for the suspicious behavior. The con- cerned person should take the suspect- ed nurse aside and let him or her know that patient care might be jeopardized
by the suspected nurse’s actions.1 The individual should express concern for the nurse’s well-being. Examples of statements of concern are, “You aren’t as clear in your charting today as you usually are,” or, “You made three mis- takes in your charting today. Is some- thing wrong?”
Initiating communication in an hon- est and concerned manner will set the stage for frankness in future dialogues. Although, in the short run, being direct can cause the substance-dependent nurse to make greater efforts to hide his or her substance abuse; it also can become the first step in the rehabilita- tion process.2
If the suspected nurse admits to hav- ing a problem with substance abuse, the initial intervention is to listen and let the nurse talk about his or her concerns and problems. A friendly, open conver- sation is an appropriate beginning. If the listener feels that the nurse current- ly is impaired, he or she should guide the nurse to meet with a manager
Home Study Program Substance abuse among nurses—
Intercession and intervention MMAANNAAGGEEMMEENNTT
• IT IS NOT EASY to report a coworker who may have a substance abuse problem, so many nurses choose to remain silent about this issue.
• THIS ARTICLE PROVIDES suggestions for staff nurses about how to confront a peer, docu- ment inappropriate nursing behaviors related to substance abuse, and report these issues to a man- ager. The manager’s role in counseling and inter- cession with a substance abusing employee also is detailed.
• REMEDIATION AND SUPPORT programs are addressed along with return-to-work issues and the need for education about this debilitating dis- ease. AORN J 82 (November 2005) 777-799.
ABSTRACT
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immediately. An impaired nurse should not be allowed to continue to practice. If this nurse is not currently impaired, the listener should help him or her set up a meeting with the manager to discuss the problem. This nurse needs to be strongly encouraged and guided to obtain professional help. This is some- thing the manager can arrange. A staff nurse should not accept the suspected nurses’s confession and promise to seek help on his or her own; follow-through is paramount.
If, however, the suspected nurse
denies accountability for his or her actions, the concerned individual should report the suspected nurse while adhering strictly to established policies and protocols.3 Reporting a colleague or staff member who is suspected of sub- stance abuse requires evidence not sup- positions or gossip. Hearsay or subjec- tive information should be eliminated, and the focus should be placed on the facts only.3
Accurate, clear documentation of evidence is imperative to ensure that an innocent person is not accused unjustly. Narrative summaries or journal entries are forms of documentation that can be used, or an incident report can be gen- erated.3 Documentation should be con- fidential; objective; specific; detailed with dates, times, and places; and should describe in detail what was observed.2 If another coworker also has witnessed an event, that person should countersign the entry, if possible.3 Obtaining corroboration from col- leagues can be helpful during the reporting process. Inappropriate or sus- picious behavior also can be document- ed. The information should be first- hand, and the tone should not be sar- castic, blaming, judgmental, or nega- tive.2 The nurse’s job performance is the focus at all times. Table 1 provides a list of rules for reporting.
The concerned individual first should report the suspected nurse to the manager and then to other admin- istrators if the manager does not inter- vene.1 The concerned individual should allow the manager or adminis- trator the chance to change the situa- tion before considering filing a com- plaint with the state board of nursing or going public with more extreme measures (eg, providing negative information to the print and broadcast media). It is best not to risk damaging the reputation of a health care facility with negative publicity, if possible.
TABLE 1 Rules for Reporting a Colleague
Who May Have a Substance Abuse Problem1,2
Be knowledgeable—Know the signs and symptoms of impairment.
Document facts clearly, concisely, and with dates.
Do not assume that it will be possible to remain anonymous as the reporter.
Do not be surprised if some colleagues retaliate (eg, the cold shoulder, overt harassment, increased work- load, denigration of personal competency or integrity).
Do not gossip—Malicious gossip can tarnish the nurse’s reputation.
Focus on the disclosure, not on the personality of the person being reported, by providing objective data; personalizing disclosures could result in a lawsuit for libel or slander.
Have other professionals verify the information, if possible, to lend objectivity.
Maintain confidentiality.
Use institutional channels of communication before considering going public.
Write a clear, short summary of the information and provide the source of the information.
1. “Blowing the whistle on incompetence: One nurse’s story,” Nursing 19 (July 1989) 47-50. 2. A Taylor, “Support for nurses with addictions often lacking among colleagues,” The American Nurse 35 (September/October 2003) 10-11.
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Copies of any correspondence should be kept for the reporting party’s protec- tion should retaliation result. If the report is written in good faith, the reporter is protected from reprisals,1 and an employer cannot take action against the reporting nurse, even if the allega- tions turn out to be false.4 It is important, however, not to malign another person’s name in speech or in writing, and this could result in a defamation of character lawsuit.4 Most importantly, fear should not stop the concerned person from being a patient advocate.5,6
THE NURSE MANAGER’S ROLE
Nurse managers are responsible for ensuring that staff members assigned to their units provide at least a minimal level of care. Managers need to develop an educated eye and a proactive approach to confronting nurses suspect- ed of substance abuse. In reality, however, nurse managers often are not prepared to confront nurses who may be involved in potentially unsafe practices. It is espe- cially stressful to confront a nurse who is a valued employee. To ensure the provi- sion of quality nursing care, nurse man- agers must learn to detect behaviors that warrant action.7,8 It is incumbent on nurse managers to be knowledgeable about chemical dependency and to learn its signs and symptoms. Nurse man- agers need to raise their index of suspi- cion for this illness.2
Managers should support the nurses on their units and emphasize their eth- ical duty to report unusual behaviors or patterns. Reporting is critical—no one can correct a problem unless a report- ing mechanism is solidly in place. Staff members also should be empowered to take action without fear of reprisal. The nurse management team must estab- lish a culture that encourages active reporting and corrective action and that is not punitive.8-10 Nurse managers also
are responsible for creating a work cli- mate in which impaired workers can face the truth and seek treatment. Finally, nurse managers should contact local law enforcement officials and the state board of nursing to learn how impaired nurses will be treated in their respective states.5
Early intervention is critical, as is providing support for the nurse sus- pected of substance abuse. Under- standably, employers are very con- cerned about potential lawsuits for negligent re- tention of impaired nurs- es. According to an attor- ney, “the minute you have knowledge or per- ceive that the person is substance abusing. . . . you have got to bring this person in and confront him [or her].”11(p38) If a plaintiff is able to show that a nurse manager knew about the substance abuse problem but failed to act, the plaintiff also can sue under the “theory of negligent supervi- sion.”12 Keeping the prob- lem quiet is condoning the substance abusing nurse’s behavior, and the manager becomes part of the problem instead of part of the solution.12 “By failing to act on evidence . . . the administrator does not meet a professional obligation (and, some- times, a legal one) to safe- guard patients.”13(p21)
Managers should not be impulsive; rather, they should be cautious, inves- tigate, and plan strategically before engaging in counseling or intercession with a suspected employee. The first step a nurse manager must take is to
Managers should establish a culture that encourages
active reporting and one in which impaired workers
do not fear punishment so they can
face the truth and seek
treatment.
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addicted nurse must reach “rock bot- tom” before he or she will avail him- self or herself of treatment options; however, it also is
exceedingly rare for any chemically addicted person to spontaneously gain insight into the true nature of her or his problem without the help of an outside source presenting real- ity in a receivable way.2(p116)
In terms of motivators, few things are as important to the alcohol or drug abuser as keeping his or her job.5
The manager must document all rec- ommendations made or actions taken. Sometimes the interaction pattern becomes circular. In other words, the manager confronts the impaired nurse, the impaired nurse temporarily cor- rects the suspected behavior or hides the problem for a short time, the man- ager relaxes the level of supervision, the impaired nurse goes back to his or her usual behaviors, and the manager confronts again. If this occurs, there is no advantage in continuing one-on-one counseling.2
THE INTERCESSION If disciplinary issues persist, the
nurse manager should arrange an inter- cession (ie, a hearing). One person may not be able to penetrate a chemically dependent nurse’s strong defense mechanisms of denial, rationalization, minimization, and projection.2 One researcher demonstrated that a group of significant persons (ie, immediate fami- ly members, employers, coworkers, close friends, extended family mem- bers) who present reality in a receivable manner so that the suspected abuser does not become defensive and close out the information will carry more weight and accomplish more than one person acting alone can achieve.14 Intercessions can be peer mediated or
obtain facts and document the nurse’s performance by reviewing recent nar- cotic sheets and other medication records and noting signs and symp- toms displayed by the nurse.7 Before meeting with the nurse, the manager should meet with members of the facility’s legal, employee health, and human resources departments. If the suspected nurse is accused of stealing medications, hospital administrators
may be required to file charges based on state and federal law.7
The nurse manager should inform the sus- pected nurse that a meet- ing is necessary because of recent concerns about his or her work perform- ance. The manager should meet with the nurse in a quiet, private setting and should confront the nurse with facts, not accusa- tions, that focus on specif- ic, documented perform- ance issues.7 The manager should discuss where job performance is inade- quate, state what per- formance is expected, identify consequences for continued poor perform- ance, and make a manda- tory referral for counsel- ing. The impaired nurse needs to understand that problems exist and that he or she is responsible for correcting them.
The nurse manager should express concern for the nurse and let the nurse know that he or she is considered to be someone with an illness for which help is available. The manager should describe resources available for the nurse and help the nurse review his or her options.7 It is a myth that an
It is a myth that an addicted nurse
must reach “rock bottom”
before considering treatment
options, but chemically
addicted people rarely gain insight
into their problems
spontaneously.
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management oriented. Any type of intercession requires strict confidentiality to protect the nurse’s rights to privacy.
PEER-LEVEL INTERCESSION. With peer inter- cession, colleagues of the same status level in the organization are chosen from that nurse’s department or another unit. This group listens to the nurse’s state- ments, and then brings the reality of the problem behaviors back into focus for
the nurse. The approach is direct and honest. This forum can be beneficial for some nurses to see where they have gone astray. The idea behind this approach is that infor- mation may be more read- ily received by a chemical- ly dependent nurse when it is delivered by peers who face the same daily struggles rather than by a supervisor. Hierarchical reporting can make the nurse defensive at the onset, and the action can be perceived as discipli- nary in nature. Peer-level intercession can be effec- tive in persuading a nurse with a substance abuse
problem to voluntarily enter treatment, although the degree of leverage, typical- ly, is decreased without the manager’s presence.2 Before and during the inter- cession, peers may consult with a thera- pist trained in intercession techniques.2
MANAGEMENT-LEVEL INTERCESSION. A man- agement intercession should include the nurse manager, although the nurse manager to whom this nurse reports may be excused from this group, depending on the circumstances; a human resource administrator; a repre- sentative from the facility’s employee assistance program (EAP); and a staff nurse. This interdisciplinary interaction provides a broader viewpoint. The man-
ager has the power to enforce the deci- sions rendered, which sends a strong message to the suspected nurse.
PLANNING THE INTERCESSION. One type of intercession includes three phases: planning, staging, and holding a group conference.14 Two to four people are selected and meticulously prepared to act as effective interceders. It is impor- tant that the people selected are appro- priate and effective in this role. Meeting with a strong group of people provides a powerful message to the nurse with a substance abuse problem. The interces- sion can be held with or without a man- agerial-level person present and with or without a therapist physically pres- ent (ie, a therapist may not be directly involved, but may act as a coach before- hand).2
The goal of the intercession is to obtain a willingness on the nurse’s part to accept help and follow through with a fitness-to-practice evaluation.3 It is important to create a controlled inter- cession during which the sole focus is the nurse’s performance in hope that he or she can face reality and no longer deny the need for treatment.5
After the interceding committee has been chosen, the committee members should • select a private place and time for the
meeting; • determine seating arrangement (eg,
chairs in a circle); • identify the preferred method to doc-
ument the intercession (eg, audio- tape, written notes, videotape);
• nominate a leader to keep the inter- cession on track;
• research available resources (eg, alternative programs, EAP);
• learn state board of nursing report- ing requirements;
• make arrangements and provide support and assistance for entry into treatment (eg, inpatient versus out- patient, health insurance clearance,
Two to four appropriate people who would be
effective in this role are selected and meticulously prepared to act as interceders.
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work clearance, child care arrange- ments, packing); and
• determine disciplinary actions if the nurse fails to comply with recom- mendations.2,3 Before the intercession occurs, a ther-
apist or social worker evaluates the data collected and educates intercession group members on alcoholism and drug addiction. Participants are given the freedom to vent anger and other negative feelings. The group members discuss their doubts, fears, and worst- case scenarios. Strategies are discussed for avoiding interruptions or unexpect- ed outbursts and for counteracting con- tinued resistance. Finally, the group members rehearse by role playing and developing an opening greeting to the nurse.2
HOLDING THE INTERCESSION. The team leader carefully presents an overview of the nurse’s work record and then listens to the nurse’s explanation of his or her behavior. Committee members then decide on a course of action, and the majority rules. If the employee is not ter- minated, he or she is required to attend treatment. Repeat offenders do not have the peer-review process as an option and can be terminated.11
When the intercession begins, the leader should adhere to the plan even if the suspected nurse actively uses defense mechanisms (eg, denial, rationalization, projection). Excuses and alibis are mani- festations of the disease and are to be expected; however, facts presented by the suspected nurse should be consid- ered. In maintaining objectivity, the team leader should request that the impaired nurse be evaluated by a physician who can order various diagnostic laboratory tests. A positive report from the laborato- ry does not automatically identify an individual as an illegal-drug user. A physician with knowledge of substance abuse disorders should be responsible for reviewing and interpreting positive
results. He or she must give the individ- ual an opportunity to discuss a positive result and must take into consideration the individual’s medical history—a posi- tive result could occur because the indi- vidual has consumed legally prescribed medications while off duty.15
If the employee refuses to participate in the intercession or undergo a physi- cian’s evaluation, the manager should begin disciplinary procedures that include written warnings, suspensions, and termination with reporting to the state board of nursing if this is deemed necessary.2 It is hoped, however, that as the nurse is presented with the negative consequences and evidence of the prob- lem, his or her “denial will . . . crack or even visibly crumble.”2(p119) Table 2 describes some “do’s and don’ts” for an intercession. The intercession concludes either when the treatment plan is accept- ed or when the intervening group receives a refusal to comply.2
OUTCOME OPTIONS FOR AN INTERCESSION The outcome of the intercession
could be • a warning, • probation, • a mandated treatment program,
TABLE 2 Intercession Do’s and Don’ts1
Do Prepare a plan. Review documentation. Request help from other departments. Ask the nurse to listen before he or she responds to
interveners. Focus on job performance. Expect denial. Report as necessary to state alternative programs or the
board of nursing. Debrief the interveners.
Don’t Just react. Intervene alone. Diagnose the problem. Use labels. Expect a confession. Give up.
1. J Daprix, “The courage to care: Intervening with col- leagues who demonstrate signs of impairment,” The Florida Nurse 51 (September 2003) 28.
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• suspension, or • termination with or without a report
to the state board of nursing.5 Deciding whether to randomly test
an employee for alcohol or drugs while continuing his or her employment, send the employee to rehabilitation, discipline the employee, or terminate the employee may depend on the state in which the employee works. Treatment should be offered in lieu of termination, at least initially. Regardless of the path chosen, the first step is to remove the employee from the work environment immediately if he or she displays inappropriate or questionable behaviors during the intercession. Whether the employee is permitted to return to work the next day or should be suspended will
depend on the circum- stances and the decision made by the manager. Suspension allows time for the manager to con- sult further with the human resources depart- ment, protects the em- ployee and his or her coworkers from a work- related injury, and pro- tects patients.11
The least helpful action a manager can take is to allow a quiet termination or encourage the nurse to resign because the nurse can then move to another workplace where the cycle will repeat itself. In this simple and quiet scenario, the nurse does not receive help, and the public remains unprotected. It is easy for a nurse who is abusing substances to secure another job because of the current nursing shortage.5
“A nurse manager ’s decision to report [the nurse] to the state board of nursing is an individual and difficult one.”2(p123) It depends on whether • the state has a mandatory reporting
law; • the state has diversion legislation (ie, a
rehabilitation option in lieu of disci- pline) and rehabilitation programs;
• a hazard exists that poses a threat to public health and safety;
• the nurse admits to diverting con- trolled substances (eg, stealing from a patient’s medicine drawer) when confronted;
• the nurse is motivated to seek treatment; or
• there is evidence of satisfactory par- ticipation in a treatment program.2 Depending on facility peer-review
The Effect of After-Work Activities on a Career
How a nurse behaves while off-duty can significantly affect anemployer’s handling of that employee. Employers today are doing “whatever they can to ensure that the people they hire will safeguard the patients entrusted to their care.”1(p71) Scrutinizing and monitoring employees’ off-duty conduct, therefore, has become increasingly acceptable. “If a nurse’s behavior off the job suggests that [he or] she could endanger patients in any way, [the] employer can take disciplinary action against [the nurse], including termination.”1(p71)
Being under the influence of alcohol or drugs while on the job can be grounds for immediate disciplinary action or dismissal. Abusing alcohol or drugs on a nurse’s own time while off-duty may have similar consequences.
Employers may receive information about employees’ inappropri- ate off-duty activities from colleagues or from law enforcement authorities. For example, in New Jersey, law enforcement authorities are required to report nurses and physicians who are charged with criminal activity to their respective boards. The board then may report the issue to the employer. If a nurse is arrested, the employ- er can discipline or dismiss the nurse if it can be determined that the behavior that led to the arrest indicates the nurse poses a dan- ger to patients and is likely to violate patients’ rights. State boards can use the arrest as a springboard to launch a full investigation into the nurse’s practice. The nurse’s medical records and other information can be subpoenaed. When criminal charges are resolved, the board still can pursue disciplinary action.1
1. D L Mantel, “Off-duty doesn’t mean off the hook,” RN 62 (October 1999) 71-74.
SIDEBAR
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processes and state-specific board of nursing requirements, nurses may be reported to the state board of nursing after termination, or they can be report- ed if a concerned individual has a strong suspicion, based on clues such as med- ication errors. If a state’s board of nurs- ing identifies rehabilitation as an option, reporting usually is a good idea. These alternative programs are designed to ensure that the public’s health and safe- ty are not jeopardized.2 Many states also have programs that reintroduce the nurse into the workplace under a moni- tored system of checks and balances for the nurse’s and patients’ protection.7
Managers have the authority and responsibility to support, advocate for, initiate, and direct a process for leading colleagues to appropriate treatment options. Treatment plans can be strong- ly suggested or mandated as a condi- tion of continued employment. The real issue is not whether to treat, but rather how many times to send a nurse back for rehabilitation. Treating relapse one, two, or three times is considered acceptable; beyond this, it is consid- ered a form of enabling.11 Conse- quences for noncompliance should be set forth clearly.
It is “no longer excusable [for man- agers] to stand idly by and watch profes- sional colleagues be destroyed. . . .”2(p119) Written policies and procedures are required that deal fairly, effectively, and humanely with the issues of chemical impairment—both before treatment and when the nurse returns to practice.2 Suspension or revocation of the nurse’s license by the board of nursing should be a final action when treatment is refused or unsuccessful.16
REMEDIATION AND SUPPORT PROGRAMS The ultimate goal of remediation and
support is to provide nonpunitive, con- fidential, voluntary programs focused on rehabilitation and reentry into prac-
tice while ensuring public safety.17 Some examples of rehabilitation programs are psychological/behavioral modification, aversion therapy, and detoxification.18 A nondisciplinary approach can protect the public from unsafe practitioners while concurrently promoting treat- ment and rehabilitation for the im- paired nurse. Proponents of this approach find it to be cost-effective and successful.19 By treating the impaired nurse, not only is he or she helped on a personal level, but another nurse has been retained in the workforce.16 With this approach, it is more prob- able that nurses will self- report and report others earlier.17
Treatment can be per- formed on an outpatient or inpatient basis, depend- ing on the degree to which the nurse is addicted and the type of support system (ie, enablers versus tough love) the individual has. Treatment on an outpa- tient basis can require as many as four visits a week for a period of one to three months, followed by less frequent visits each week for a few more months or longer. Inpatient treat- ment can be performed daily at first and then fol- low the same frequency as outpatient treatment.20 Employees should pay for at least part of their treat- ment in order to increase their accountability and commitment to the process. Three recov- ery programs noted in the literature are the Recovery and Monitoring Program (RAMP), Health Professionals Recovery Program (HPRP), and Texas Peer Assistance Program for Nurses (TPAPN).
Remediation and support should
include nonpunitive, confidential,
voluntary rehabilitation
programs focused on reentry into
practice while ensuring
public safety.
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THE RAMP PROGRAM. The RAMP pro- gram, offered in New Jersey, is designed to encourage health professionals to disclose their dependencies and seek recovery with confidential oversight by the New Jersey board of nursing. The program offers • addiction education, • advocacy services for employers,
• assistance in commu- nicating with licensing boards,
• confidential data col- lection to provide evi- dence that the nurse is maintaining recovery,
• urine testing, and • an independent re-
source for treatment options.
The program is available to help those who are seri- ous about recovering and requires periodic reporting from the employer. The rate of recovery for health care professionals who are monitored is 80% to 90%;20 relapse is common in unmonitored substance abusers. The RAMP pro- gram also provides re- sources for those col- leagues who are resentful of the recovering nurse or who no longer trust the nurse.20
THE HPRP PROGRAM. Michi- gan’s voluntary program, HPRP, guarantees confi-
dentiality and allows the nurse to avoid the licensing board’s disciplinary track. Nurses who suspect another nurse of abusing substances can report that nurse to HPRP without jeopardizing the sus- pected nurse’s livelihood. This program encourages nurses to err on the side of helping their colleagues rather than ignoring the problem.21
THE TPAPN PROGRAM. The TPAPN pro- gram is a nondisciplinary program for nurses with chemical addictions and some mental illnesses. The nurse manag- er or employer can contact the program’s 24-hour helpline with concerns about a specific nurse. The suspected nurse then is given the option of participating in the peer-assistance program or being report- ed to the state board. Not surprisingly, 60% of the nurses choose to enter the pro- gram.17 The TPAPN treatment program lasts four weeks, and the nurse then attends ongoing self-help meetings or therapy and agrees to undergo random drug testing. The addicted nurse also is assigned a volunteer nurse advocate who provides ongoing support. The TPAPN participant is responsible for his or her testing and treatment costs.17
PEER-ASSISTANCE PROGRAMS. Many states offer peer-assistance programs to help nurses with drug or alcohol problems. Interestingly, married nurses have been shown more likely to successfully com- plete a peer-assistance program.22 This is attributed to the support provided by a family unit. As expected, support sys- tems (eg, friends, family members) are crucial for success.
Services that usually are offered with peer-assistance programs include • intervention, • referral, • education, • peer-support groups, • regionalized state-wide contacts, • reentry monitoring, and • a hotline telephone number.22 In one study, 66% of the nurses referred to a peer-assistance program made positive progress and completed their program.22
EMPLOYEE ASSISTANCE PROGRAMS (EAPS). An EAP is a referral program for employees who have personal problems that affect their performance at work.18 The EAP provides a counselor who is a licensed mental health professional. Employee assistance programs are contracted by
Employee assistance programs
provide a licensed mental health counselor who performs an
evaluation, makes an assessment,
and then recommends treatment options.
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health care facilities for the benefit of their employees. The counselor performs an evaluation that includes obtaining a sub- stance abuse history and performing an assessment and then recommends treat- ment options.20 The EAP can provide counseling or can monitor the employee’s progress while other outside agencies provide the counseling.
BENEFITS OF ALL PROGRAMS Treatment programs include any or
all of the following facets: • motivational intervention, • detoxification, • education, • drug screening, • coping skills, • self-help recovery, and • the Alcoholics Anonymous or Nar-
cotics Anonymous 12-step programs. Employees should be required to sign a letter of commitment to stay drug- and alcohol-free, continue to attend after- care, report to the counselor, and submit to 20 to 40 unannounced random drug tests in the first year.
The typical cost savings for these programs are substantial compared to the cost of investigation, disciplinary actions, and incarceration of an em- ployee added to the cost of replacing a knowledgeable nurse.17 Employees who are motivated to seek treatment return to the workplace as productive employees 85% of the time,16 and those employees who remain sober in the first year are likely to stay clean.11 These alternate programs allow the nurse to begin treatment and recovery
TABLE 3 Where to Get Help
Al-Anon A program where relatives and friends of alcoholics can share their experiences, hope, and strength to solve common problems. All people who are affect- ed by another person’s drinking can use this organ- ization to help find solutions to relationship issues. (800) 356-9996 http://www.al-anon-alateen.org
Alcoholics Anonymous (AA) This program is a fellowship where men and women can share their experiences, strengths, and hopes with others during the recovery period. It is a 12-step program of total absti- nence by staying away from alcohol one day at a time. (212) 870-3400 http://www.alcoholics-anonymous.org
American Council on Alcoholism The prime focus for this group is educating the public about the effects of alcohol, alcoholism, and alcohol abuse. The Council advocates prompt, effective, and readily available and affordable treatment programs. It provides sup- port groups and news updates on relevant top- ics. The Council works with the court system to incorporate treatment programs for drunk-driv- ing offenders. (800) 527-5344 http://www.aca-usa.org
Cocaine Anonymous The program provides support for those depend- ent on cocaine. Although this group is not affili- ated with AA, the AA 12-step program and ideals are followed. (800) 347-8998 http://www.ca.org
Institute for a Drug-Free Workplace This coalition of businesses and individuals is dedicated to serving the rights of both the employer and employees in the workplace. Drug abuse prevention with efforts to influence national debate on these issues is the focus of this coalition. Recognizing the pervasive substance-abuse problems facing the United States, this organization promotes drug testing, user accountability, employee-assistance pro- grams, and education. (202) 842-7400 http://www.drugfreeworkplace.org
Nar-Anon This is a 12-step program designed to help rela- tives and friends of addicts recover from the effects of dealing with this stressful illness. This group helps those who know or have known a feeling of desperation due to the addiction prob- lems of someone close to them. (310) 534-8188 http://www.nar-anon.org
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in tandem with continuing to practice as a nurse or to resume practice when treatment is completed and the nurse is deemed competent and fit to practice again.23 Organizations that provide help are listed in Table 3.
RETURN-TO-WORK ISSUES Early in the treatment program, the
counselor, the impaired nurse, and the nurse manager should discuss reentry into the workforce.2 Disagreement exists about how long a manager should wait before allowing an employee to return to work. A general time frame is six to 12 months, depending on the degree of addiction, severity of signs and symp- toms, and commitment of the nurse to recover.2 On return to work, the newly recovered nurse should
• not be placed in clinical settings where there is exposure to the indi- vidual’s drug(s) of choice;
• not be expected to handle any type of controlled substances for the first six months, followed by another six months in which controlled sub- stances are handled under direct supervision;
• be limited to practice in areas that are less stressful (eg, long-term care units, ambulatory care settings, utilization review, nursing education, interim positions that are created to meet the temporary needs of the facility);
• limit work hours to either part time or full time with restrictions on overtime (eg, none allowed) and shift (eg, day shift and evening shift rather than night shift);
TABLE 3 Where to Get Help
National Association for Children of Alcoholics (NACA) The NACA advocates for all children and families affected by alcohol and other drug dependencies. (301) 468-0985
National Clearinghouse for Alcohol and Drug Information (NCADI) Along with providing research databases and a listing of relevant publications, NCADI pro- vides self-help resources, resource guides, a listing of treatment facilities, and referrals. The NCADI covers all topics related to alcohol and drug dependency and recovery and includes all subgroups affected by this illness. (800) 729-6686 http://www.health.org
National Council on Alcoholism and Drug Dependence Hopeline (NCADD) The NCADD operates a network of affiliates with advocacy, education, prevention, and treatment programs. This agency for substance-abuse treat- ment programs provides written information and referrals for treatment and counseling through- out the country. The organization advocates using ED DIRECT for interventions: • Empathy—adopt a warm and reflective under-
standing style. • Directness—maintain eye contact and speak
directly about the issue.
• Data—provide feedback and state concerns clearly.
• Identify willingness to change. • Recommend actions and advice. • Elicit a response. • Clarify and confirm actions. • Telephone referrals. (800) 622-2255 http://www.ncadd.org
National Institute on Alcohol Abuse and Alcoholism (NIAAA) The NIAAA provides leadership in the national effort to reduce alcohol-related problems using research, collaboration with other institutes, and the dissemination of information to health care providers, researchers, policy makers, and the public. Pamphlets and brochures also are provided, clinical trials are discussed, and databases and resource listings are available. (202) 842-7400 http://www.niaaa.nih.gov
Substance Abuse and Mental Health Services Administration (SAMHSA) The SAMHSA compiles a national directory of more than 11,000 drug abuse and alcoholism treat- ment programs, including residential treatment centers, outpatient treatment programs, and inpa- tient hospital-based programs. http://www.findtreatment.samhsa.gov
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It is incumbent on the manager to carefully analyze any new charges against the recovering nurse. The man- ager should ensure that the returning nurse is treated fairly and that his or her privacy is upheld.2 If a manager notes odd behavior from the returning nurse and believes the nurse may be under the influence of substances, and if state law and unions permit random screening processes, the nurse should be tested. The employee is the only person who has the right to know the results of the drug screening. These results can be shared with the manager only if the information is relevant to job performance. Search- ing employees and their personal property (eg, lockers, desk drawers) is acceptable if it is written in the facility’s policy. Physical searches are per- mitted but must be per- formed with great care so that the person perform- ing the search is not sub- ject to assault and battery charges.25
Should a relapse occur, the nurse manager must take it seriously and deal with it immediately by relieving the nurse of his or her duties and placing the nurse on medical leave of absence until the matter has been satisfactorily resolved. Failure to honor commitments could result in immediate termination without pay and being reported to the state board of nursing.11
In general, state boards of nursing are abstaining from taking formal discipli- nary actions if the nurse is willing to seek treatment and abide by a prearranged contract.23 If this approach proves unsuccessful, however, disciplinary
• work only in a structured setting under direct supervision, but never alone; and
• submit to on-the-job, random, super- vised drug and alcohol screening.2 Return-to-work agreements in con-
tract form should specify conditions and expectations of continued employment along with clearly stated consequences of failure to adhere to the terms (Figure 1). Administrators need to provide guid- ance to the returning chemically dependent nurse while simultaneously protecting the institution’s interests. The measures taken are designed to • enhance recovery by monitoring the
nurse’s attendance at self-help group meetings and counseling (eg, indi- vidual, group) sessions;
• ensure safety and decrease the chance of relapse; and
• enforce policies by delineating the consequences of a relapse or viola- tion of the agreements.24
Signing a contract can emphasize the reality and seriousness of the situation to the impaired nurse. It is a very help- ful tool in breaking down the nurse’s denial and preventing enabling on the part of the nurse manager.2
When a nurse is given appropriate treatment, he or she should be encour- aged and supported with reentry issues. Nurse managers are facilitators for recovering nurses returning to work and should provide supportive envi- ronments. In addition, the manager must ensure that reentry into the work- force is supervised and structured, par- ticularly in the area of drug access. The nurse manager should • constantly evaluate the nurse’s com-
pliance with treatment recommen- dations and the human resources department’s program or EAP,
• ensure that the nurse is maintaining a satisfactory job performance, and
• provide for supervised, random urine, saliva, and/or blood sample testing.2
Signing a return-to-work contract can
emphasize to the impaired nurse the seriousness of the situation
and can be helpful in breaking
down denial.
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FIGURE 1 Sample Return-to-Work Agreement1
Date Employee Name Address
Dear _______________ (employee name):
Your return-to-work date has been designated as ________ (date). Please report to your nurse manager on this day at ____ AM/PM (time) with this signed agreement. Read the letter in its entirety before signing the agreement. Your signature on this document is required for you to return to work. If you have any questions, please contact the human resources department at __________ (telephone number).
These are terms to which you will agree in order to return to work and to retain your position at ___________________________ (facility name).
Per our agreement, I will work _____ hours per day, _____ times a week on the ____________ (day or evening) shift. I will not ingest any substances (ie, drugs, alcohol) that may alter my mood or affect my performance, and I will disclose any medications prescribed to me that may have the potential to do so. I understand that supervised, random urine and blood tests will be performed to assess my compliance during my recovery period, and I agree to such interventions performed by the hospital. I also expect the hospital to maintain my privacy and keep all information obtained confidential, although I understand it may be necessary to share the results with my nurse manager.
I will continue to participate in my _______________________ (self-help group, peer-assistance meetings, individual counseling sessions) ______ times each week. I will advise my nurse manag- er when the frequency of these meetings changes or they are terminated (ie, when the counselor and I agree on the final date). I give permission for my nurse manager to contact _______________ (counselor) for updates on my progress during my treatment regimen.
I understand that my job performance will be monitored daily and that an evaluation will be con- ducted on a weekly basis initially, with less frequent meetings thereafter as determined by the nurse manager. It is expected that my evaluation will be at least “satisfactory” in order for me to maintain my position.
I will not be allowed to administer or count controlled substances. It is the nurse manager’s responsibility to determine when it will be appropriate for me to return to performing these job functions.
I fully understand that if I fail the blood or urine random tests; discontinue my counseling ses- sions without the agreement of the counselor; fail in performing my job as required; abuse sub- stances (ie, drugs, alcohol); or have any disciplinary action taken against me that I may be sus- pended, terminated from my position, and/or reported to the state board of nursing.
As an active participant in my recovery, I will maintain contact and seek the support and advice of my nurse manager if I feel I might be relapsing.
I am willingly signing this contract, recognizing my obligations and accountability for my actions.
_______________________________________ ____________________ Signature of nurse Date
_______________________________________ ____________________ Signature of nurse manager/human resources manager Date
________________________________________ ____________________ Signature of counselor Date
1. N B Fisk, D A Devoto, “The nurse employee who uses alcohol/other drugs,” Nurse Managers Bookshelf 2 (December 1990) 122.
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action may be warranted. Discipline ultimately can have a positive effect be- cause it allows the abuser time to reflect on the preceding events and analyze errors. Some nurses who are disciplined are able to gain greater insight into their past behavior, retrospectively recognize that they wanted and needed help, and view the violation and resultant disci- pline as a “wake up” call.8 All nurses should be helped with their recovery efforts, but at some point, nurse man- agers must recognize that the impaired nurse’s desire to change may not be possible. If the nurse falters is his or her commitment, disciplinary actions must be the next step.
STAFF MEMBER ACCEPTANCE AND SUPPORT Often employers who retain chemi-
cally dependent nurses do not provide formal return-to-work agreements to help these nurses be successful. In addi- tion, some nurses may make it difficult for recovering nurses to be accepted back into their roles.23 Nurses who return to work may be greeted with mistrust and covert anger from their coworkers. Some nurses even display overt anger and resentment. “The view of the addic- tion as a moral or ‘bad’ behavior issue rather than as a disease remains a preva- lent one.”2(p126) Recovering nurses may be treated with distrust, disdain, and avoidance, especially if coworkers feel that special contractual agreements and differential treatment place an undue burden on them.2 Sabotage of the recov- ering nurse also has been known to occur.2
If confidentiality is not an issue (ie, the treated nurse’s colleagues are aware of the reason for the nurse’s absence), the team should participate in a team- oriented training session so they can learn how to interact with this nurse on his or her return. Recommended steps nurses can take to support a colleague in recovery are noted in Table 4. The nurse
manager should let staff members express their feelings and then actively engage them in the nurse’s reentry process—this will give them a sense of control and help them feel less victim- ized (eg, at having to work more shifts or undesirable shifts). Open communi- cation is the best course of action.2
GROUP COHESIVENESS Prevention program effectiveness
requires supportive elements in the work environment. Coworkers can have either a positive or negative influence on employees with alcohol or drug prob- lems. Coworkers may either help employees seek rehabilitation or actively enable the impaired nurse by unwittingly covering for that person. Intragroup rela- tions that include the substance-abusing employee should be considered in pre- vention efforts. Substance abuse pro- grams and educational efforts cannot ignore contextual elements—focusing on the individual alone is not as effective as looking at group dynamics.26
Teamwork and group cohesiveness are important for prevention and are associated with a decreased likelihood of alcohol problems or drinking climates. In cohesive groups, norms dictate fair
TABLE 4 How to Support a
Colleague in Recovery1
Do not be judgmental or condescending.
Step in and help the nurse when a situation develops.
Be honest—Tell the nurse when troubling behaviors are apparent.
Be ready to intervene.
When others alienate the nurse, discuss this behavior with them.
Involve managers.
Ask questions and learn about recovery, addiction, and relapse.
1. A Taylor, “Support for nurses with addictions often lacking among colleagues,” The American Nurse 35 (September/October 2003) 10-11.
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distribution of work, cooperation, inter- dependence, and addressing rather than avoiding problems. Cohesive groups produce conformity and rule compliance with minimal support for deviant behav- ior. These factors mitigate substance abuse in a team environment because abuse is seen as a minority behavior and is associated with negativity from coworkers.25
EDUCATION Nurse managers must
halt rumors and gossip and take positive actions to both inform and coun- sel staff members when a recovering employee re- turns to the workplace. The manager should launch an educational effort to provide employ- ees with current perspec- tives of substance abuse as an illness and facilitate discussion. The educa- tional program should facilitate an institution- wide change of attitudes and behaviors.
Education can play a direct role in preventing drug and alcohol problems among nurses. Nurses should be reminded about the toxic effects of drugs and alcohol on the body, the pharmacology of sub-
stances, and the addictive process. It is paramount that the manager focus on the signs and symptoms of early alcohol or drug problems and strategies for inter- vention and assistance.22
Most importantly, nurses should be taught how to deal with the problem of an impaired colleague. It is especial- ly hard to confront another nurse when the substance is legal, such as alcohol. Practical advice and tips for
dealing with an impaired nurse are lacking. Questions that should be dis- cussed with and clarified for staff members include • how severe must misuse of a sub-
stance be for it to be considered a medical problem? and
• how much is too much?27 The manager should provide staff
members with handouts on effective listening tips and guidelines for approaching an employee who has a problem. The manager also should instruct staff members on how to respond to resistance when they are trying to encourage a colleague to get help. The manager should make every effort to alleviate fears of placing a nurse’s job in jeopardy so that the nurse will seek treatment.26 One model to help nurses seeking advice on work- ing with an impaired nurse is the NUDGE model: • notice, • understand, • decide, • use guidelines, and • encourage.26 In this model, one nurse plays the part of the employee with a substance abuse problem during a role play. Another nurse nudges the impaired nurse to get help while a third nurse observes.
Not only should education on sub- stance abuse be presented as an inser- vice program for all employees, it should be on the orientation agenda for newly hired employees. During facility orientation, newly hired employees at all staff levels should be educated on the illness itself and the facility’s fitness-for-duty policy that clearly states what is expected of employees in performing their duties. The policy should present clear guide- lines and precise steps for reporting incidents in which substance abuse is suspected.28 The policy also should provide contingency plans for steps to
Nurse managers must halt rumors and gossip and take positive
actions to inform and
counsel staff members when a
recovering employee
returns to the workplace.
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NOVEMBER 2005, VOL 82, NO 5 Dunn
be taken if an employee is declared unfit for duty and stipulate negative actions for being impaired at work. These policies should be established, operationalized, and implemented and should focus on caring for the impaired employee.2,27,28
Health care facility administrators are responsible for increasing aware- ness of chemical dependency, providing education, and providing impaired employees with assistance. Administra- tors should ensure that a work environ- ment exists that “encourage[s] safe, qual- ity practice, as well as physical and psy- chological well-being.”7(p37) Healthy work cultures emphasize employee involve- ment; family-friendly policies that pro- mote work-life balances (eg, child care); peer support; and a positive flow of communication. Work-life balance is a key facet for organizational wellness.26
EARLY ACTION AND EDUCATION Institutions should have policies in
place to “treat and retain—not ignore and release—chemically dependent employees.”24(p56) In helping an im- paired nurse, early action and educa- tion are critical. Nurses should explore and express their attitudes, beliefs, and fears about addiction. They should be able to discuss interventions with an impaired nurse, and, most importantly, they should be able to identify their own responsibility for action.27 “Eras- ing punitive, negative attitudes toward impaired nurses and replacing them with supportive, positive ones must be a goal for [everyone].”29(p10) It is each nurse’s responsibility to educate him- self or herself about addiction and recovery to increase empathy for the substance abusing nurse.
The good news is that nurses can and do recover from addictive illness and return to productive lives. This recov- ery is facilitated when coworkers and
supervisors meet their ethical (and often legal) obligations to their col- leagues, the public, and the profession by identifying and intervening in cases of impaired practice.13(p24) ❖
Debra Dunn, RN, MBA, CNOR, is the nurse manager of the OR at St Joseph’s Wayne Hospital, Wayne, NJ.
This article is dedicated to a nurse with whom the author once worked in hopes that she finds her way.
The author acknowledges Eleanor Silverman, MLS, AHIP, St Joseph’s Wayne Hospital Library, Wayne, NJ, for her assistance in acquiring resources for this article.
NOTES 1. D L Mantel, “Off-duty doesn’t mean off the hook,” RN 62 (October 1999) 71-74. 2. N B Fisk, D A Devoto, “The nurse employee who uses alcohol/other drugs,” Nurse Managers Bookshelf 2 (December 1990) 110-129. 3. J Daprix, “The courage to care: Inter- vening with colleagues who demonstrate signs of impairment,” The Florida Nurse 51 (September 2003) 28. 4. D Serghis, “Caring for the carers: Nurses with drug and alcohol problems,” Australian Nursing Journal 6 (June 1999) 18-20. 5. H Creighton, “Law for the nurse manag- er: Legal implications of the impaired nurse—Part I,” Nursing Management 19 (January 1988) 21-23. 6. “Blowing the whistle on incompetence: One nurse’s story,” Nursing 19 (July 1989) 47-50. 7. S Ponech, “Telltale signs,” Nursing Management 31 (May 2000) 32-37. 8. D Booth, A K Carruth, “Violations of the nurse practice act: Implications for nurse managers,” Nursing Management 29 (October 1998) 35-39. 9. C Dunbar, “Verifying nurses’ backgrounds: How much should we know?” Nursing Spectrum (Jan 26, 2004) 16-18. 10. L W Mustard, “Caring and competen- cy,” JONAs Healthcare Law, Ethics, and Regulation 4 (June 2002) 36-43. 11. J Gemignani, “Substance abusers. Terminate or treat?” Business and Health 17 (June 1999) 33-39.
Healthy work cultures emphasize employee involvement; family-friendly policies that promote work-life balance
(eg, child care); peer support; and a positive flow of communication.
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12. W A Maggiore, “Substance abuse: When the system fails,” Journal of Emergency Medical Services 21 (November 1996) 70-80. 13. E J Sullivan, “Impaired nursing prac- tice: Ethical, legal, and policy perspec- tives,” Bioethics Forum 10 (Winter 1994) 20-25. 14. V E Johnson, I’ll Quit Tomorrow, second ed (New York: Harper & Row, 1982). 15. D M Bush, J H Autry, “Substance abuse in the workplace: Epidemiology, effects, and industry response,” Occupational Medicine: State of the Art Reviews 17 (January-March 2002) 13-25. 16. H Creighton, “Legal implications of the impaired nurse—Part II,” Nursing Management 19 (February 1988) 20-21. 17. S Trossman, “Nurses’ addictions: Finding alternatives to discipline,” American Journal of Nursing 103 (September 2003) 27-28. 18. J Ossi, “Substance abuse and depend- ence in the hospital workplace: Detection and handling,” Perspectives in Healthcare Risk Management 11 (Spring 1991) 21-26. 19. “National council compares two regula- tory approaches to the management of chemically impaired nurses: An interim report,” Issues 18 (1997) 7, 16. 20. M Kinsley, “A helping hand to freedom: Programs help nurses with substance abuse problems get back on the road to recovery,” Nursing Spectrum (Nov 15, 2004) 10-11.
21. C West, “A person who is sick deserves the chance to get well,” Michigan Nurse (November 1997) 4-6. 22. L Finke et al, “Nurses referred to a peer assistance program for alcohol and drug problems,” Archives of Psychiatric Nursing 10 (October 1996) 319-324. 23. “Voluntary programs encourage impaired nurses to admit problem,” ED Management 9 (December 1997) 147-148. 24. B L Peery, G W Rimler, “Chemical dependency among nurses: Are policies adequate?” Nursing Management 26 (May 1995) 52-56. 25. “Consider liability issues when manag- ing drug-impaired staff,” ED Management 9 (December 1997) 148-150. 26. J B Bennett et al, “Team awareness for workplace substance abuse prevention: The empirical and conceptual development of a training program,” Prevention Science 1 (September 2000) 157-172. 27. J M Supples, “My colleague, my friend: The impaired nurse,” Nursing Management 21 (August 1990) 48I-48P. 28. L E Rozovsky, F A Rozovsky, “Blowing the whistle on incompetence,” Canadian Criti- cal Care Nursing Journal 7 (June 1990) 12-13. 29. B E Calfee, “The state license hearing— Information for empowerment,” Revolution— The Journal of Nurse Empowerment 8 (Spring 1998) 20-21.
An alert issued by the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) reports that patients undergoing chemo- therapy to fight leukemia and lymphoma are some- times accidentally being injected with a powerful anti-cancer medication in an incorrect way that results in death or permanent paralysis, according to a July 14, 2005, news release from JCAHO. The medication vincristine has been used widely and successfully to treat cancer for many years, but sometimes the medication is mistakenly adminis- tered in the sac around the spinal cord (ie, intra- thecal) instead of intravenously.
Intrathecal administration of vincristine can be the result of a single error or a series of mis- takes in a medication system, and these errors have continued to occur despite repeated warnings and extensive labeling requirements and standards. The Joint Commission alert recommends that
health care organizations • dilute the medication in such volume that it
prevents intrathecal administration; • clearly label all vincristine syringes with the
warning that vincristine is fatal if given intrathecally and is for IV use only;
• ensure that IV and intrathecal medications are dispensed or administered at different times and in different locations; and
• have at least two caregivers conduct a time out before the patient receives vincristine to inde- pendently confirm the correct patient, medica- tion, dose, and route for administering the medication.
Joint Commission Issues Alert: Mixups in Administering Chemotherapy Drug Lead to Deaths (news release, Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, July 14, 2005).
Chemotherapy Medication Mixup May Be Fatal
Examination NOVEMBER 2005, VOL 82, NO 5
AORN JOURNAL • 801
1. Documentation about a colleague suspected of substance abuse should
1. be confidential. 2. be objective and specific. 3. be detailed with dates, times,
and places. 4. include only facts not suspi-
cious behaviors. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
2. An employer can take action against a reporting nurse if the alle- gations turn out to be false. a. true b. false
3. When planning for a mediation, a manager should
1. obtain facts and document the nurse’s performance.
2. review narcotic sheets and other medication records.
3. objectively document signs and symptoms of substance abuse.
4. have a physician knowledgeable about substance abuse disorders review and interpret positive laboratory results.
a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
4. One type of intercession includes 1. holding a group conference. 2. planning. 3. peer reviewing. 4. staging. 5. treating.
a. 1, 2, and 4
b. 2, 4, and 5 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
5. The outcome of a hearing held after several weeks of ongoing dis- ciplinary issues could be
1. allowing the employee to quit. 2. a simple warning. 3. a mandatory treatment program. 4. probation. 5. suspension. 6. termination.
a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6
6. The most helpful action a manager can take is to allow a quiet termi- nation or to encourage the nurse to resign. a. true b. false
7. The ultimate goals of remediation and support are
1. providing nonpunitive confi- dential voluntary rehabilitation programs.
2. facilitating reentry into practice. 3. ensuring public safety. 4. ensuring that nurses who
jeopardize patient trust through substance abuse are punished.
a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4
8. Examples of rehabilitation programs include
Examination Substance abuse among nurses—
Intercession and intervention
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recog- nizes these activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider- approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
MMAANNAAGGEEMMEENNTT
NOVEMBER 2005, VOL 82, NO 5 Examination
802 • AORN JOURNAL
1. aversion therapy. 2. behavioral modification. 3. desensitization therapy. 4. detoxification. 5. psychological modification.
a. 1, 3, and 4 b. 2, 3, and 5 c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
9. Employees should not be required to pay for any part of their treat- ment because financial stress often causes them to revert to old habits. a. true b. false
10. Signing a return-to-work agreement 1. emphasizes the seriousness of
the situation to the impaired nurse.
2. is helpful in breaking down denial.
3. helps prevent enabling on the part of the nurse manager.
4. provides guidance to the return- ing chemically dependent nurse.
5. protects the institution’s interests.
a. 1 and 3 b. 2 and 4 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
The Agency for Healthcare Research and Quality(AHRQ) has launched a new program to help cli- nicians and patients determine which medications and other medical treatments are most effective for certain health conditions, according to a Sept 29, 2005, news release from the AHRQ. The Effective Health Care Program is a $15 million, three-part pro- gram that incorporates 13 new research centers and a center dedicated to communicating findings. Program researchers will help provide clinicians and patients with better information for making treat- ment decisions by reviewing and synthesizing pub- lished and unpublished scientific studies and identi- fying important issues where existing evidence is insufficient.
The program includes the following three components. • Developing comparative effectiveness reports—
Researchers at an existing network of 13 evidence-based practice centers will focus on comparing the relative effectiveness of differ- ent treatments, including medications, as well as identifying gaps in knowledge where new research is needed.
• Implementing a network of research centers—A new network of 13 Developing Evidence to Inform Decisions about Effectiveness research centers (ie, DEcIDE centers) will carry out accel-
erated studies, including research aimed at fill- ing knowledge gaps about treatment effective- ness. The centers will use de-identified data available through insurers, health plans, and other partner organizations to answer questions about the use, benefits, and risks of medications and other therapies. Collectively, the DEcIDE centers will have access to de-identified medical data for millions of patients, including Medicare’s 42 million beneficiaries.
• Making findings clear for different audiences—A new Clinical Decisions and Communications Science Center will focus on improving commu- nication of findings to a variety of audiences, including consumers, clinicians, payers, and health care policy makers. The center will trans- late findings in ways appropriate for the needs of different stakeholders and will conduct its own program of research into effective commu- nication of research findings in order to improve usability and rapid incorporation of findings into medical practice.
AHRQ Launches New “Effective Health Care Program” to Compare Medical Treatments and Help Put Proven Treatments into Practice (news release, Rockville, Md: Agency for Healthcare Research and Quality, Sept 29, 2005).
New Program Compares Medical Treatments
Answer Sheet NOVEMBER 2005, VOL 82, NO 5
AORN JOURNAL • 803
Answer Sheet Substance abuse among nurses—
Intercession and intervention lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or
make photocopies and mail to:
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2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
or fax with credit card information to (303) 750-3212.
Additionally, please verify by signature that you have reviewed the objectives and read the
article, or you will not receive credit.
Signature ________________________
1. Record your AORN member identifi- cation number in the appropriate sec- tion below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions one through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the amount of time you required to complete this 4.7 contact hour (235- minute) program.__________ 4. Enclose fee if information is mailed.
P
AORN (ID) # _______________________________ Name _____________________________________ Address ___________________________________ City_______________________________________ State __________ Zip ____________ Phone number______________________________ RN license #________________________________ State __________________________ Fee enclosed _______________________________ or bill the credit card indicated ■■ MC ■■ Visa ■■ American Express ■■ Discover Card # ____________________________________ Expiration date
Signature _________________________________________________ (for credit card authorization)
Event #05092 Session #7238
Contact hours: 4.7
Fee: Members $23.50
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Program offered
November 2005
The deadline for this
program is Nov 30, 2008
A score of 70% correct on the examination is required for credit.
MMAANNAAGGEEMMEENNTT
NOVEMBER 2005, VOL 82, NO 5 Learner Evaluation
804 • AORN JOURNAL
Objectives To what extent were the following objectives of this Home Study Program achieved? 1. Discuss how a nurse should report
a colleague suspected of substance abuse.
2. Explain the nurse manager’s role in counseling and intercession with a substance abusing employee.
3. Identify the outcome options for an intercession with a nurse suspected of substance abuse.
4. Identify return-to-work issues in regard to keeping the suspected nurse in the workforce.
5. Explain how staff member acceptance can enhance treatment program success.
Content To what extent 6. did this article increase your know-
ledge of the subject matter? 7. was the content clear and organized? 8. did this article facilitate learning? 9. were your individual objectives met? 10. did the objectives relate to the over-
all purpose/goal?
Test Questions/Answers To what extent 11. were they reflective of the content? 12. were they easy to understand? 13. did they address important points?
Learner Input 14. Will you be able to use the infor-
mation from this Home Study in your work setting? a. yes b. no
15. I learned of this Home Study via a. the Journal I receive as an AORN
member. b. a Journal I obtained elsewhere.
c. the AORN web site. d. the AORN manager’s web site.
16. What factor most affects whether you take an AORN Journal Home Study? a. need for contact hours b. price c. subject matter relevant to current
position d. number of contact hours offered
What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be inter- ested in writing an article on this topic? Topic(s): ___________________________ ___________________________________ Author names and addresses: ________ ___________________________________
Learner Evaluation Substance abuse among nurses—
Intercession and intervention
This evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate these items on a scale of 1 to 5.
Purpose/Goal: To educate perioperative nurses about the problem of substance abuse among nurses.
MMAANNAAGGEEMMEENNTT
