Florida Recognizing Impairment in the Workplace

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This fulfills the continuing education requirement of 2 contact hours on Recognizing Impairment in the Workplace for the state of Florida.    

Up to 20% of nurses in the United States are chemically dependent. Substance use disorders, addictions, drug diversions, and other related impairment processes present a threat to the health and safety of those around them. Increasing in concern are overdoses and deaths that are on the rise due to substance abuse and addiction. Early identification of the signs and symptoms of a substance abuse disorder in the workplace contributes to reducing the risk and harm to patients and other healthcare team members. Co-workers play a crucial role in recognizing and reporting suspicious behaviors to their supervisors or appropriate personnel. 

Introduction – Florida Recognizing Impairment in the Workplace

Impairment within the workplace of a healthcare environment is, unfortunately, more common than one may realize. Impairment results when a healthcare professional cannot provide competent and safe patient care because they may be impaired by alcohol, prescription, or non-prescription drugs, or other mind-altering substances (2).  Impairments can also result from a psychological or neurological condition that may affect a person’s judgment. Because of impairment, the healthcare professional is unable to perform duties essential to their profession safely. 

Acknowledging the Problem 

Ideally, from a professional standpoint, healthcare personnel should acknowledge their condition and seek help voluntarily without requiring intervention; however, this is often not the case. Co-workers play an important role in helping the impaired person get treatment. Often, the abuser has denial with the condition, the social stigma, or fear of potential job loss. Colleagues are often reluctant to report their co-workers because they feel it is not their responsibility. They feel like the individual they are reporting may be punished excessively. They may believe that someone else has already addressed the issue or fear the loss of their colleague’s job or license. Despite these potential reasons, colleagues may have certain legal responsibilities in identifying and reporting. States may have specific reporting laws that could hold colleagues responsible for harm to patients if they fail to report.

Definitions 

Substance Use Disorder :  a disease of the brain characterized by the recurrent use of substances such as alcohol and drugs that cause clinical and functional impairment such as health problems, disability, and failure to meet responsibilities at work or school.  

The disease involves reward, withdrawal, memory, and motivation and can be classified as mild, moderate or severe depending on the level of impairment (1).  

Addiction:  the most severe, chronic stage of substance use disorder. There is a substantial loss of self-control, indicated by compulsive substance use despite the desire to stop using (1). 

Drug Diversion:  is the transfer of any substance from the purpose for which it was intended for any illicit use, such as personal use or sale (1). 

Impairment: is the inability or impending inability to engage safely in professional and daily life activities as a result of physical, mental, or behavior disorders such as substance use, abuse, or addiction (1). 

Impairment Behaviors in the Workplace  

Some behaviors are associated with emotional problems but are specific to alcohol or other drug abuse. Some signs common to alcohol and other drugs may also be signs of psychological or psychiatric conditions (2). Each situation is individualistic to the person. Health care professionals must be educated appropriately regarding the signs and symptoms of chemical dependence. The workplace is often the last place that addiction may manifest; disruptions in family, personal health, and social life can happen while the workplace remains unaffected.

Behaviors Associated with Substance Abuse

• Severe mood swings/personality changes 
• Frequent or unexplained tardiness, work absence, illness, or physical complaint 
• Elaborate excuses 
• Under-performance 
• Difficulty with authority 
• Poorly explained errors, accident, or injury 
• Confusion, memory loss, difficulty concentrating 
• Visibly intoxicated 
• Refuses drug testing 

Signs Associated with Substance Abuse

• Unreliability in keeping appointments and meetings 
• Trouble with relationships (professional familial, marital) 
• Physical indications such as track marks or bloodshot eyes 
• Signs indicative of drug diversion 
• Deterioration in personal appearance 
• Significant weight loss or gain 
• Discovered comatose or dead  

Signs and Behaviors Associated to Drug Diversion Specific to Anesthesia Personnel (1)   

• Consistently uses more drugs for cases than colleagues. 
• Frequent volunteering to administer narcotics, relieve colleagues for casework
  
• Heavy wastage of drugs 
• Frequent trips to the restroom or breaks 
• Drugs and syringes in pockets 
• Anesthesia record does not match up with drug dispensed and administered to patient 
• Patient has unusually significant or uncontrolled pain after anesthesia.
  
• The patient has a higher pain score as compared to other anesthesia providers. 
• Times of cases do not correlate when provider dispenses drug from automated dispenser 
• Inappropriate drug choices and doses for patients are made by the provider 
• Missing medications or prescription pads  

Substances such as opioids (e.g., morphine and fentanyl), inhalational anesthetics and volatile agents (e.g., sevoflurane, nitrous oxide), and intravenous anesthetic agents (e.g., propofol) are readily available to many healthcare providers (1). Despite medication dispensing and audit controls in place, drugs can be diverted for misuse. This may happen through the procurement of medicines directly from the pharmacy, automated dispensing units, retrieval from sharps containers of medication remaining in syringes, directly from patient medications, or indirectly through dilution of a medication that appears that nothing is missing from the container (1).

Regardless of the substance being abused, impairment in the workplace can negatively impact patient and provider safety. Facilities should have policies and education addressing symptom awareness, prevention, and reporting to help minimize the risk of diversion and adverse outcomes. Studies have shown that substance use disorder is a disease of the brain (1). As a responsible healthcare provider, by arming yourself with knowledge and the signs and behaviors of impairment in the workplace, it will prevent further harm. 

Healthcare providers are usually successful at disguising their issues or potential signs are ignored because they are respected or an intelligent member of the healthcare team. Significant changes in behavior in the workplace may various many causes. If signs of substance abuse and drug diversion are left unrecognized or reported, the user may be placed in danger and patient safety compromised. Impaired health professionals sometimes develop coping mechanisms that allow them to cover up their diminished capacity to provide safe and efficient patient care. Eventually, mistakes are made, including medication and procedural errors that become apparent to their co-workers (3).

Consequences of Drug Diversion and Substance Use in the Workplace  

Healthcare providers are responsible for their patients’ safety, including their duty to deliver safe and competent care without impairment. Impairment in the workplace can create a disorganized environment (1). The consequences to associate with substance use and drug diversion in the workplace may cause the following consequences for the patient themselves, their colleagues, and the facility in which they are employed. 

Patient

• Pain, anxiety, and side effects from improper dosing 
• Allergic reaction to wrongly substituted drug 
• Victim of medical errors
  Loss of trust in the healthcare system
  Communicable infection from a contaminated needle (1) 

Impaired Professional

• Adverse health effects related to abuse 
• Chronic health problems (heart disease, liver impairment) 
• Familial and financial difficulties 
• Loss of social status 
• Felony prosecution, incarceration, and civil malpractice 
• Actions against a professional license 
• Accidents resulting from physical harm (1) 

 Colleagues

• Injury or infection from blood-borne pathogens from improperly stored equipment 
• At risk for shared-patient care responsibilities with an impaired professional resulting in adverse patient outcomes 
• The stress of increased workload from an impaired healthcare team member 
• Disciplinary action for false witness of leftover medication, improper disposal, or failure to report (1) 

 Facility   

• Costly investigation 
• Civil liability for patient harm 
• Damaged reputation due to public knowledge of mandatory reporting or drug diversion instances, especially those that led to patient harm 
• Poor work quality 
• Loss of revenue from diverted drugs or reimbursement from adverse events due to impaired provider (1) 

The use of addictive substances over time may result in the deterioration of the healthcare professional’s overall health. For example, the use of stimulants may result in cardiovascular problems such as angina, hypertension, and Myocardial Infarction. Alcohol can lead to liver disease, such as cirrhosis. Depression, suicide, and anxiety are mental health disorders that are often coexisting problems with substance abuse. The healthcare workers’ impairment can also lead to traumatic injuries such as falls, fractures, and head injuries (1).

Florida Rules and Regulations  

Many states have rules and regulations regarding the use of alcohol and controlled substances that include disciplinary action. Drug diversion is a significant offense that is taken very seriously. Almost every state requires the reporting of a health practitioner who is suspected of impairment in the workplace. The penalties associated with this vary state by state. Florida requires that all nurses take a Florida Recognizing Impairment in the Workplace CE course every other renewal to improve the recognition and outcomes of workplace impairment.

The state of Florida has an efficient reporting system. Nurses report to the Florida Department of Health or Intervention Project for Nurses (IPN). The IPN’s mission is to enhance public safety by assisting nurses and other nursing related personnel whose practice may have been impaired by substance abuse (4). Their call of the acknowledgment of impairment remains confidential. The Intervention Project for Nurses in Florida allows for an opportunity for intervention and the monitoring of nurses that are using alcohol or controlled substances (4). 

The IPN after receiving a referral of impairment will:  

• Initiate a consultation 
• Provide an intervention 
• The nurse will be required to stop practicing within 1-3 days-the entire process may take up to 12 months
• Assist the person in obtaining the appropriate treatment needed
• Evaluate the progress of the person and the adherence to their treatment plan
• Continuously monitor the person for 2-5 years

Reporting and Intervention  

Once a nurse or other employee has determined that there is an issue with a coworker regarding impairment in the workplace, an intervention must occur to prevent further harm from happening to patients, themselves, or other co-workers. According to the Intervention Project For Nurses, the co-worker determines that there is sufficient evidence and documentation to support their concerns of the impairment of a health professional, an intervention should be planned (4). The planning and participation related to such intervention is usually the responsibility of the employee’s nursing manager. 

• Intervention process steps: (4)  
• Prepare a plan 
• Review documentation 
• Request help from others 
• Ask the person to listen to what is said before allowing them to respond 
• Stick to their job performance 
• Have evaluator options ready 
• Expect denial 
• Report as necessary to the Board
  

Return to Practice  

A recovering nurse’s return to practice requires planning and oversight by a nursing manager. Once a nurse has been determined that they are safe to return to practice, several things must fall into place. These things include developing a return to practice guidelines for that specific employee, such as returning to work agreement. Experts must also advocate for the employees to return to work, provide support, review expectations, monitor requirements, and answer questions (4).

Considerations Of Relapse 

Substance use is a chronic illness that comes unfortunately with periods of remission and exacerbation. The rate of relapse among nurses is lower than the general population (4). This is due to several factors, such as support programs and stringent state monitoring programs. Despite the fact, some nurses relapse. Knowledge of the management of relapse in the workplace is a crucial part of impairment in the workplace and plays a significant role in the safety of patients and other employees (4).

Conclusion – Florida Recognizing Impairment in the Workplace

Substance abuse is a chronic and progressive disease. Being able to recognize impairment in the workplace is imperative for the safety of patients, the impaired person, and other co-workers. Impairment can come in many forms. Being knowledgeable of the signs and symptoms as well as reporting responsibilities and policies will not only improve safety but also improve the overall practice environment. Nurses can be very good at picking up subtle clues as to another individual’s impairment. Be aware, be knowledgeable, and be supportive. 

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