Impaired practice: The reality of a taboo topic
Martie L. Moore, RN, MAOM, CPHQ
My first experience dealing with impaired practice in the healthcare setting came when I was a young nurse. I just passed my boards and was still a novice nurse in my practice.
He was a well-known physician with a reputation for rounding after dinner. Many times, he would have a drink or two and then come into the hospital and see his patients — also common knowledge among staff.
One night, he arrived to do rounds and asked me to join him. As we walked down the hallway he stumbled. The odor of alcohol hit me when we entered the first patient room. He was impaired and should not have been making rounds, let alone driving. I was a brand new nurse and unsure of what to do.
The situation was layered in complexity and safety issues. Patient safety was paramount, yet I remember thinking I could lose my job for speaking up. I did so eventually and he sought treatment for his addiction.
I wish I could tell you this was an isolated incident. Sadly, I have dealt with a variety of examples of impaired practice. Diversions for private use. Stealing narcotics to sell on the black market. Using both illegal and prescription drugs in the workplace. The stories go on and on.
Impaired practice is a significant issue and needs to be taken seriously. Nationally, we are in an epidemic of opioid addiction. This is not a black-and-white situation when it comes to care providers. Many have chronic pain from job-related injuries or strains.
There becomes then the dual challenge of chronic pain management and monitoring for a substance use disorder. Many studies through programs within the Boards of Nursing have found that addicted nurses openly identify that pain led to overuse or abuse of prescription drugs.
The call of action for leadership is in three areas:
1. Educate yourself about substance abuse disorders, signs and symptoms of impaired practice. Familiarize yourself with legal requirements under individual state and professional board's regulations as well. Lean into the experts regarding the latest evidence and research in this field.
You do not need to be an expert yourself but need to have a strong foundation of understanding. Get to know your internal policies on diversion and impairment before you need to use them. I guarantee there will be a time that you will need to use them and learning while you are dealing with the situation is not the best scenario, for all involved.
2. Be vigilant about prevention of diversion. Automated medication systems are good but not foolproof. Diversions can and do happen with them. Audit automated drug dispenser reports on a routine basis. Regularly monitor how drugs are administered, wasted and documented. Secure access areas where narcotics are stored.
Monitor access and do random spot checks to assure accuracy with the count. Fentanyl patches and Emergency Drug Boxes are two of the high-risk areas for long-term care settings. Fentanyl has, on the average, 28% to 84% of the medication remaining after 72 hours of application. Nurses divert patches by: removing the patch from the resident and keeping it; dispensing a new patch and keeping it, only to move the used patch to another part of the patient's body; removing the medication from the patch with a syringe and then applying the patch; removing patches from sharps containers and other mechanisms to access the drug.
3. Seek help if you have a care provider coming back to the workplace after treatment. You need to understand what they can and cannot do. You want to help them to continue to advance in their recovery work by not placing them into an unsafe or difficult situation. In most programs, they will have randomized drug testing while in the workplace. You will need to think through how to accommodate the testing and maintain confidentiality.
These situations are never easy and clear cut. Leaders need to tap into resources to guide them through how to manage both the individual with impaired practice and their organizations.
Many co-workers will experience anger at the individual person for stealing or using drugs, or behavioral issues. They may not want the person back and do not understand the disease of addiction.
Re-entry to the workplace can be difficult for all involved. Leaders need to set expectations of what re-entry will look like for the individual and the co-workers.
I once was asked if it is worth the effort to try to support a caregiver through the treatment and back into the workplace. The individual asking me had just had an employee relapse and was back into treatment again after stealing drugs from the hospital.
The statistics are not good when you look at the percentages of those who do relapse within the first five years. But I also reflect on an outstanding nurse leader I know who early in her career dealt with her own addiction issues. She shared that if it wasn't for the support and belief of those she worked with, she would be dead. They supported her through treatment and a relapse. They cheered her on as she won her license back and went back to get an advanced nursing degree. Today, she is helping others and is a shining example behind why we should act.
September 18-24 was recently proclaimed Prescription Opioid and Heroin Epidemic Awareness Week. When you factor in the U.S. Surgeon General's recent plea to clinicians, and new courses like the one from Medline University specifically geared toward recognizing the signs and symptoms of opioid abuse and explaining treatment options, we all play an important role in positively impacting this epidemic. Already, the course has been taken by nearly 1,000.
The question is: Will we have the courage to act upon speaking up and providing support when dealing with colleagues, patients and residents when we spot it?
Martie Moore, RN, MAOM, CPHQ is the chief nursing officer at Medline Industries Inc. and a corporate advisory council member for the National Pressure Ulcer Advisory Panel.