CHEMICAL DEPENDENCY AND IMPAIRMENT IN THE WORKPLACE

Impairment from substance abuse, drug diversion, or other physical or psychological causes has far-reaching impact. It not only threatens the health and safety of patients but also creates serious consequences for the impaired professional, colleagues, and the healthcare facility that employs the impaired clinician.

The Nurse Worklife and Wellness Study found that in the year prior to the study illicit drug use among nurses was 5.7% and misuse of prescription drugs was 9.9% (Trinkoff et al., 2022). The exact number of nurses afflicted is unknown, but the prevalence of addiction among nurses is believed to mirror the general population. In 2020, an estimated 37.3 million Americans aged 12 or older were current illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 13.5% of the general population aged 12 or older (SAMHSA, 2021c).

Risk Factors for Substance Abuse

Healthcare professionals may be at increased risk for abuse of prescription-type medication due to the added risk of working in environments where frequent and easy access to controlled substances is part of their daily work routine. For instance, evidence suggests the types of drugs abused by nurses may depend on what drugs are most accessible in their individual work environments. The most common prescription drugs abused by nurses are benzodiazepines and opioid analgesics. Nurses who abuse prescription drugs are those who have the greatest access, such as nurse anesthetists (American Addiction Centers, 2022).

Signs of Substance Abuse and Impaired Practice

Impairment renders a clinician unsafe to provide patient care. Physical, psychosocial, and behavioral clues, however, can be subtle and easily overlooked. Colleagues may notice clues but seek other explanations and avoid suggesting substance abuse as a possible cause.

Generally, disruptions in family, personal health, and social life manifest long before an individual shows evidence of impairment at work. Thus, all indicators, no matter how subtle, appearing in the workplace must be taken seriously. Any of the following may be signs of impairment in the workplace, and patterns of such behavior and a combination of these signs are cause for increased suspicion.

COMMON SIGNS OF IMPAIRMENT

Type	Signs
(Nyhus, 2021; AANA, n.d.; Toney-Butler & Siela, 2020)
Physical	Progressive deterioration in personal appearance Wearing long sleeves when inappropriate Diminished alertness, confusion, or memory lapses Frequent runny nose Dilated or constricted pupils Bloodshot or glassy eyes Unsteady gait Slurred speech Diaphoresis Frequent nausea, vomiting, or diarrhea Tremors or shakes, restlessness Weight gain or loss
Psychosocial	Increasing isolation or withdrawal from colleagues Personal relationship problems Dishonesty with self and others Intoxication at social functions Defensiveness (e.g., denial, rationalization) Inappropriate verbal or emotional responses Mood swings, overreaction to criticism, overexcitement Personality change (mood swings, anxiety, panic attacks, depression, lack of impulse control, suicidal thoughts or gestures, feelings of impending doom, paranoid ideation) Feelings of shame, guilt, loneliness, sadness
Behavioral	Absenteeism (absences without notification, excessive use of sick days, excessive tardiness) Confusion, memory loss, and difficulty concentrating or recalling details and instructions Ordinary tasks requiring greater effort and consuming more time Frequent complaints of vague illness, injury, pain Insomnia Rarely admitting errors or accepting blame for errors or oversight Unreliability in keeping appointments and meeting deadlines Work performance that alternates between periods of high and low productivity Working excessive amounts and showing up on days not scheduled Making mistakes due to inattention, poor judgment, bad decision-making Sleeping on the job Elaborate, implausible excuses for behavior

Intervening and Reporting Impaired Practice in a Colleague

When planning to intervene in a case of suspected impairment, the first step is knowing state laws and rules pertaining to substance abuse and impairment in the workplace. It is also important to be familiar with and to follow the organization’s policies and procedures relating to substance abuse and impairment.

Healthcare professionals can follow these steps when they begin to notice possible impaired practice in a colleague:

• Observe job performance; be aware of signs and symptoms of impairment that are common in the workplace.
• Look for patterns of behavior indicating possible impairment that are consistent over a period of time.
• Document (date, time, place, witnesses) any inappropriate behavior; be concise and include objective, clear, and factual information:
• What happened?
• Who was involved?
• When did the incident occur?
• How was it discovered?
• Where did it occur?
• Were there any witnesses?

Supervisors should be involved in planning an intervention and taking steps to respond to concerns about impairment in the workplace.

• Planning and participating in an intervention is a critical responsibility of the manager, and it should never be implemented alone.
• It is important to develop a careful plan of action before implementing an intervention and also important to secure help.
• Interventions should focus on documented facts.
• The primary objective of an intervention is to request the clinician refrain from practice until a fitness-to-practice evaluation has been completed (IPN, 2023).
• To assure safety, a clinician who is impaired should never be left alone and should not be permitted to drive.

State practice acts typically require licensed healthcare professionals to report any other similarly licensed professional when they reasonably believe that the practitioner is or may be guilty of unprofessional conduct or unfit to practice. State laws similarly include confidentiality provisions for the person who makes such a report and also provide for immunity from civil or criminal prosecution for good faith reporting. All licensed healthcare professionals must become familiar with the requirements of the applicable practice act and laws in their own jurisdiction.