Assisting the impaired clinician
How to overcome barriers to recognition
By the time the general public hears about an impaired clinician, whether it's a nurse, technician, or physician, it is often too late to head an incident involving that clinician off at the pass-whether that incident is a medical error, diversion of medication, or something even worse, like the technician recently accused of inadvertently exposing thousands of patients to hepatitis C.
But the healthcare industry is well aware that impaired clinicians exist, and it has methods for addressing, confronting, and helping these medical professionals. Where are the industry's gaps to success in preventing this far too common occurrence? BOJ recently sat down with Jill Pollock, RN, LMFT, administrator of Loma Linda University Behavioral Medicine Center and frequent lecturer on chemical dependency recognition and intervention, to discuss this topic.
It takes a case as shocking as the hepatitis C outbreak in New Hampshire to bring a topic like this to light, she says.
"I think it's difficult for people in healthcare to wrap their heads around it," says Pollock. "What do you think one of our biggest barriers is to recognition of addiction and confronting it? If I can get people to talk just a little bit, we start hearing how there is a fear that confronting someone's addiction could ruin someone's life."
For many healthcare professionals, the thinking is backward, she says-they're focused on saving a coworker's career. But we have a professional responsibility to our patients, our loved ones, and the public in general.
"What happens if someone drives impaired and kills someone in a car crash? Would you worry about their professional life?" says Pollock. "Or if your facility has an outbreak of hepatitis C?"
After talking with audiences about the possible outcomes of not confronting versus trying to help the impaired professional, she has found that the best tactic is to bring in personal, relatable example scenarios. "If someone is diverting drugs, then that patient, that mother or father, son or daughter, husband or wife, is not getting their pain medications," she says. "Or, alternately, is being cared for by an impaired nurse. I try to bring it home to something we can all relate to."
Who would you want taking care of your loved one? Pollock asks. Would you be comfortable with a caregiver who is impaired or thinking about where to find his or her next fix?
But it isn't just about scaring the audience by bringing the examples home. You have to teach compassion as well, says Pollock.
"The best antidote to ignorance is education," she says. "Understanding addiction is extremely important."
Personal views on addiction will always vary, says Pollock. While there is a lot of research out there showing addiction is a disease, there will always be people for whom it is a moral issue.
"A disease is something you treat," she says. "You wouldn't tell someone there is a moral issue if they're not taking their insulin as a diabetic."
The concept of addiction as a disease is difficult for people to understand, says Pollock, even if you've been through it with a loved one or family member.
"A lot of people have been hurt by it. There can be a reaction to throw the addicted professional in jail and revoke their license, that they've defiled their professional licensure," she says. "Really trying to educate people about addiction is so important. Just because we're in healthcare doesn't mean we understand it."
Another issue is the sheer volume of medications healthcare professionals are surrounded by. This can cause staff to lose a healthy fear and respect for how powerful medications are.
"I don't know that we have a respect for it," Pollock says. "I think we need to start early in medical school and nursing school that these are things to be revered. That is why we have systems to control them and automated machines dispensing to keep track of them."
One of the biggest challenges the industry faces is prescription drug abuse, says Pollock.
"It's available, and it's so common and doesn't take long for your body to start craving the medication," she says. "Say you have your knee replaced. It takes only a few weeks for that Percocet to start to have an effect on the body."
No one thinks as they take their first sip of alcohol that they will become an alcoholic, but nevertheless the risk is there. It's no different for someone consuming pain medication for the first time. This is why education is so vital.
"Make sure they understand addiction, that it does happen in healthcare. The oath is to do no harm, and we believe it when we say it. But life happens," says Pollock. "I think we have to raise education and awareness that it's our responsibility to protect our professions, families, and our patients."
Identifying the symptoms
After addressing the issues of education and empathy, Pollock turns to discussing how to assess someone who may be in trouble.
"There are physical symptoms and behavioral symptoms," she says.
Not all changes in mood or behavior are related to addiction, of course, but Pollock suggests paying attention if a person starts coming to work late, calling in sick, coming in on different shifts, or showing patterns of isolation.
"What might be causing the tardiness, the illness, the change in behavior?" she says.
In the '90s, Pollock says, there was an article about a nurse who showed a number of physical signs of addiction-but had reasonable excuses for all of them. If these plausible reasons exist, colleagues want to believe there is nothing wrong. Addiction is a disease of denial.
It may not be physical signs we see, though, she says. Consider behavioral signs as well. Does the employee seem too helpful? Is he or she quick to volunteer to waste drugs? Does he or she jump to cover for people at lunch or spend an inordinate amount of time at the Pyxis® machine getting meds?
Also remember that there's rarely just one sign of impairment, says Pollock.
"You want to have all of your ducks in a row. You want to take a look at everything; symptoms, change in behavior, work decline, and all of the medications you cannot account for. As we start that investigation to find if someone is diverting drugs, for example, you'll find if it's there," she says. "Eventually the addiction gets so strong that you'll find it."
Look at the big picture, she says. Say an impaired employee was scheduled to administer Demerol to patient X. Pull all the info from the medication control reports and research the patient charts-you may find that when the med was taken out, patient X was actually no longer in the hospital.
In addition, you will often find that several people who work with the impaired person have a piece of the puzzle. "Someone will come to me and say, 'I'm just not really sure. I think there's something going on,' " Pollock says. "And 100% of the time someone will chime in, a charge nurse or such, who will say yes, that person did X or Y-leaving during a code, showing up late, other signs. I may hold a piece of information; the charge nurse or staff nurse might hold another. Everybody has a little piece, but nobody stopped to look at the bigger picture to potentially think it could be a problem of addiction."
Teach your leadership what to look for-and remember that the shadow of addiction can hound anyone, even your best and brightest.
"A few years ago, I came across a story of a nurse who had never touched drugs or alcohol in her entire life," says Pollock. "She was the breadwinner for her family, including her parents and in-laws, and she was about to have her firstborn. She had to come back to work quite early and was under a tremendous amount of stress. But she never forgot the feeling when they gave her Demerol when she had the baby."
The nurse started diverting drugs. She was such an unlikely culprit that no one suspected her-until one charge nurse noted that she had been disappearing on shift. The resulting investigation uncovered a narcotics discrepancy. Everybody had a piece of the puzzle.
Approaching an impaired professional can be an intimidating endeavor, Pollock says.
"It is certainly a bit scary. Having done this more times than a person should have to, I certainly understand that," she says.
Prepare for anything-have all of your t's crossed and i's dotted. Obtain a paper trail for order discrepancies. Address the employee's work habits. Is he or she habitually tardy or calling in sick? It takes some time to gather evidence if the employee's situation is not a blatant example of impairment.
"Have all of that information in front of you, and then make sure to also have your hospital's or clinic's policy. We have a drug-free workplace policy," Pollock says.
And remember, how you feel about addiction is evident in how you treat that person.
"I just say that it's our responsibility to preserve that human being," says Pollock. "Be tender on the person, but tough on the issue."
While it is not the employer's inherent responsibility to take care of an employee with an addiction, if you don't offer the employee some assistance with his or her recovery, you are skipping a key step.
"In California, for instance, we have a diversion board. Almost every state has something like this. We have a board and a professional responsibility to report someone to the board," Pollock says.
She explains the board's role and what it offers to impaired clinicians. They don't necessarily need to lose their license. Instead, the best-case scenario is to give employees resources to get help and treatment for their addiction.
"There's a quote by Leah Curtin when she talks about the Crimean War and the term 'throwaway nurses,' " says Pollock. "Nurses who became addicted were just thrown away-they lost their license, their dignity, their pride."
We have surpassed that stage in our professional development and understanding of addiction, she says. "I think we've evolved to where this person may have been your brightest. They often are. Driven, compassionate, and they have this disease of addiction, and so if we don't get them help, what's going to happen? They will go to another hospital, and the cycle will never stop. Whether you can find the compassion for them or not, try to get them the help they need so the cycle will stop."
Stopping that cycle means no one gets hurt. That's the bottom line, says Pollock.
"My very first experience with this was in the late '70s on a night shift," she says. "I was in an isolation room in the ICU. There was a commotion outside. I looked up in time to see one of my beloved colleagues being taken away in handcuffs by two officers. It scared the daylight out of all of us. But we all realized that we had watched our friend's behavior change and didn't know what to do, so we hadn't said anything." Everyone had a little piece of the puzzle, and nobody spoke up in time.
"I hope that we have evolved to not taking someone away in handcuffs but instead having a real intervention, doing our due diligence and reporting them, but then making sure the cycle stops," says Pollock.
Dealing with an impaired clinician is one of the most demanding and sensitive situations you will ever face in your career, she says.
"It's amazing what a person will forfeit for use of a drug," says Pollock. "I've had people swear, I've had them lie, I've had them walk out, I've had people break down and sob. When they finally admit there is a problem, then we can start the process of getting them help. Many have said to me that they are grateful that someone finally found out. That's been the majority of my experience, and whether the hospital fires them or not, they get a second chance at life."