Introduction

Chemical abuse or dependence affects a significant number of healthcare professionals especially nurses. Limited data is available on the rates of incidence because substance abusing health care professionals rarely report chemical abuse/dependence for fear of disciplinary action against their license to practice. It is also difficult to gather accurate statistics because employers often fail to recognize signs and symptoms of the disease. Nurses are at particular risk for chemical abuse/dependency for many reasons. Drugs are the tools used by health care professionals to treat and help their patients. They prescribe, administer and dispense medications every day. Exposure and accessibility to mood-altering medications, pharmacological knowledge of the drugs which fosters a false sense of control and a tendency to self-treat or self-medicate are a few contributing factors. When nurses find themselves in need of relief from pain and emotional stress, they may find themselves self-prescribing or taking a medication from a patient or from the stock supply. If nurses do not suffer any negative consequences while selfmedicating, they may start doing it on a regular basis. When self-medicating, the health care professional convinces himself, its only going to happen once. Many health care professionals do not receive the appropriate intervention and treatment needed due to the lack of proper identification of a dependency problem. This modified strategic planning was made to address the concern of chemical dependency upon healthcare professionals specifically the nurses. The Plan-DoCheck-Act Cycle (PDCA) or the Deming Cycle was used. It is a successive cycle which starts off small to test potential effects on processes, but then gradually leads to larger and more targeted change. The core characteristic of this process is that it is engaged in a continuous quality improvement. Each step of the PDCA Cycle involves major activities that can give the manager opportunities to involve their staff and the chemical dependent nurses to ensure relevant, doable and successful improvement process.

PLAN-DO-CHECK-ACT CYCLE (PDCA)

or the Deming Cycle

PLAN

A. Root Cause of Drug Addiction on Nurses (5 whys) 1. Pressure in the work place. Most nurses experience the stresses and pressure of long shifts, mandatory overtime, and shift rotation which are physically taxing on their part. 2. Sudden shift of emotional and physical demands. Nurses go from one emotionally and physically demanding situation to another, with little time to decompress. Nurses often need to internalize their feelings to stay in control and make split-second, lifeand-death decisions. 3. Availability and accessibility of medications at work. Nurses work with drugs every day and sometimes leftovers become part of a nurse's addiction. 4. The acceptance that drugs have the power to help one feel and perform better. Some nurses believe that drugs can boost up their energy and enhance their capabilities to sustain the demands of their profession. 5. Familiarity with drugs and their actions. Nurses have the erroneous belief that, because of their skills and knowledge, they can self-medicate without becoming addicted. Nurses

may think their knowledge of drugs enables them to be in control of the medication. B. Goals Identify nurses experiencing mental health and drug problems that have been or are likely to be job impairing. Assist these nurses in obtaining appropriate treatment. Evaluate the nurse's return to the work force. Educate employers and nursing colleagues about the negative effects of addiction in the work place and the potential for rehabilitation and return to productive work. C. Objectives To provide screening tests and assessments on all nurses within the institution. To develop treatment plans based on the nurses identified needs. To monitor the recovering nurses functional capacity in practice. To conduct lectures, trainings and seminars to broaden the knowledge and understanding of nurses and other health care personnel on the negative effects of addiction in the work place and the potential for rehabilitation and return to productive work.

I. Do
1. Identify chemical dependent nurses

A. Conduct Pre-entry drug tests for incoming nurses and random drug test for all nurses including nurse managers within the institution. B. Observe behavioral characteristics that may occur with drug addiction.

Absenteeism absences without notification and an excessive use of sick days Frequent disappearances from the work site, long unexplained absences, improbable excuses Unreliability in keeping appointments and meeting deadlines Work performance that alternates between periods of high and low productivity Mistakes made due to inattention, poor judgment, and bad decisions Confusion, memory loss, and difficulty concentrating or recalling details and instructions Ordinary tasks require greater effort and consume more time Interpersonal relations with co-workers suffer Rarely admits errors or accepts blame for errors or oversights Progressive deterioration in personal appearance and hygiene Wearing long sleeves when inappropriate Personality change - mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures Increasing personal and professional isolation

Note that these behavioral characteristics do not always indicate drug addiction, but may warrant further investigation.

2. Encourage Treatment Because employees may still deny that theres a problem or blame the situation on personality conflict, the person is likely to resist treatment. In this case the nurse manager may have to go right to the bottom line: unless treatment is sought, job status will be affected. There are four types of treatment available for someone who is chemically dependent.

1. Inpatient/Residential Treatment: Inpatient treatment usually consists of a minimum inpatient stay of at least 28 days and medical management of detoxification. Residential treatment provides medical supervision of detoxification. The professional receiving inpatient or residential treatment is removed from the availability of alcohol/other drugs and daily outside distractions. This setting gives the individual the needed time to focus on the task of understanding and accepting the disease of chemical dependency and working on their recovery. 2. Outpatient Treatment: This type of treatment offers more flexibility and provides less disruption to the individuals everyday life than inpatient treatment. Those receiving treatment are able to remain living in their home environment and may also be allowed to continue to work. The individual receives treatment on a short term basis at the treatment providers facility. Extended Treatment: This type of treatment usually is recommended at the conclusion of a 28-day inpatient or residential treatment program. This treatment option is very structured and can range in length anywhere from two months to two years. During the period of extended treatment and rehabilitation, the individual moves into a halfway or three quarter way house and obtains employment prior to completion of the program. 3. Continuing Care/Aftercare: This type of treatment is a vital extension of the primary treatment program and ranges from six months to one year in length. Continuing care usually involves one weekly aftercare group meeting and may also include individual counseling sessions with a treatment professional. 4. Twelve-Step Meetings: Alcoholics Anonymous (A.A.) and Narcotics Anonymous (N.A.) are self-help recovery groups and are an integral part of maintaining sobriety. Generally, a minimum of at least two meetings per week are required throughout treatment and continuing care.

3. Re-entry to Practice

A health care professional that has received treatment or is in a structured treatment program for chemical dependency should be allowed to return to work only under a monitoring plan that includes an agreement or contract.

Considerations regarding readiness to return to work: a willingness to continue in a supportive continuing care program agreement to continue attending self-help meetings motivation to change lifestyles and behaviors that could trigger relapses accountability to designated personnel (i.e., PAP monitor) 4. Having a Return- to- Work Agreement

When RNs return to work after treatment for alcoholism or substance abuse, it is extremely beneficial to both the individual and the organization to have a return-to-work agreement. The agreement establishes a set of guidelines for the nurse and employer including working conditions, monitoring requirements, procedures in the event of relapse, and the length of time the agreement will be in effect, among other criteria.

SAMPLE RETURN TO WORK AGREEMENT

This agreement is to clarify expectations regarding the return to work of _____________________________at________________________________.

(health care professional)

(employer)

This agreement shall be in effect from ___________________, 20___, to ________________, 20___.The contents of this agreement are mutually agreed upon and may be modified as agreed upon by both parties. I agree to the following: 1. Abstain from the use of all alcohol/other drugs and mood altering substances. In the event that medications may be needed as a part of my health care, I agree to notify my employer by providing evidence of a prescription from a licensed medical practitioner. Over-the-counter drugs must also be reported. 2. Abide by the monitoring agreement as set forth by the Nebraska Licensee Assistance Program (NELAP). 3. Random body fluid screening at the discretion of my employer or the NE LAP. Body fluid screens will be paid for by______________________________ (employee/employer). 4. Work a schedule set by employer, ________days/hours as agreed to by both parties. 5. Not administer or have access to any controlled substances. I have read the above agreement and agree to abide by the terms thereof. I understand that if I fail to conduct myself according to this agreement, I will be subject to disciplinary action, up to, and including employment termination, and a report will be made to the State Licensing Board. ___________________________________ (Signature: Employee) ____________________________________ (Signature: Employer) ________________________ (Date) ________________________ (Date)

(It may be necessary to modify this agreement to fit individual health care professional practice and worksite expectations.)

5. Support from Staff Since everyone works as a team, staff support is critical for the recovering nurse. It may take some time for things to return to normal. One example

is the Peer Assistance Program wherein acceptance and understanding from colleagues would help hasten the recovery of the nurse involved.

6. Conduct monthly/ yearly seminars, lectures and trainings; support and promote programs and campaign for anti-drug abuse.

A written policy that is supported by top management, understood by a all employees, consistently enforced, and perfectly clear about what is expected of employees and the consequences of policy violations. A substance abuse prevention program with an employee drug education component that focuses not only on the dangers of drug and alcohol use but also on the availability of counselling and treatment. Training of managers, front-line supervisors, human resource personnel, medical staff, and others in identifying and dealing with substance abusers. An appropriate drug and alcohol testing component, designed to prevent the hiring of workers who use illegal drugs andas part of a comprehensive programprovide early identification and referral to treatment for employees with drug or alcohol problems An Employee Assistance Program (EAP) that provide counselling for employees and their family members are structured to help workers with a wide range of problems. Substance abuse is a primary concern.

7. Monitoring the recovering nurse Monitoring improves the prognosis of recovery and rebuilds trust in professional work relationships. Monitoring includes: 1. Treatment requirements, including regular phone or written progress reports. 2. A recovery plan, including requirements for continuing care/aftercare and documented attendance at Twelve-Step meetings and utilization of a sponsor. 3. Random body fluid screens, specifying who will be responsible for the cost of testing. 4. Continued utilization of a peer assistance program.

5. Regular conferences with the workplace.

II.

Check
Chemically dependent nurses were identified and provided appropriate treatments based on their needs. The recovering nurses were allowed to work under the supervision and monitoring of nurse managers and coworkers. The number of chemically dependent nurses in the institution decreased. There were good feedbacks on the progress of the recovering nurses. Recovering nurses reported that their designated treatment programs and learning were helpful in reducing and later on totally extinguished their desire to use prohibited drugs.

III. Act
The interventions were successful for the identified chemically dependent nurses. With this information, the nurse manager can continue to use these interventions for the suspected chemically dependent nurses.

References:
Nurses and Drug Addiction http://www.ehow.com/about_6393337_nurses-drug-addiction.html Drug addiction among nurses: Confronting a quiet epidemic

http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp? id=592623 Principles of Drug Dependence WHO 2008 NYSNA Statewide Peer Assistance for Nurses http://www.nysna.org/span/reentry.htm Accommodation and Compliance Series: Employees with Drug Addiction

Batiste, J.D, Linda Carter

Nurses with Chemical Dependency: Promoting Successful Treatment and Re-entry Daniel H. Angres, MD; Kathy Bettinardi-Angres, MS, APN, RN, CADC; and Wally Cross, RPh, MHS, CADC

CENTRAL PHILIPPINE UNIVERSITY

School of Graduate Studies

In Partial Fulfilment of Requirements in Nursing Service Administration I (Modified Strategic and Operational Planning)

Submitted to: Prof. Helen A. Caton R.N., M.A.N. Submitted by: Ardaine Ann Ramos R.N. MAN 1-1