Managing the Impaired Nurse - Research Paper Example

?Literature Review: Managing the Impaired Nurse A staff of competent nurses is essential to the delivery of quality healthcare. This staff will undoubtedly consist of a diverse range of individuals performing tasks that can often be stressful. Part of the nurse’s duty is to disperse medications, often narcotics and controlled substances, to their patients, which can cause temptation to abuse these substances as a means of coping with job-related and ordinary life stress factors. Detecting and managing the impaired nurse is a critical part of the leadership roles and management functions of the head nurse, which includes administrative competence, adequate education, business skills, clinical expertise and an understanding of leadership principles (Curtis, de Vries, & Sheerin, 2011). Since decision making is considered to be synonymous with management and is one of the primary criterion by which management proficiency is judged, the brunt of a manager’s time is spent critically examining issues, solving problems, and making decisions (Marquis & Huston, 2012). As an integral part of the delivery of quality healthcare, the functioning capabilities of the nurse must be on par with the standards required by the institution and the position within that institution held by the nurse. An impaired nurse, by definition, is lacking in the ability to perform their duties at a level sufficient to successfully provide their patients with quality care and meet the standards defined by their position. The complete technical definition, according to Dunn (2005) considers a nurse to be impaired “when alcohol or drug use affects their cognitive, interpersonal or psychomotor skills to the point where they can no longer satisfy their professional code of ethics or standards of practice” (p.2). As a management leader, the quality of the decisions made regarding the identification of a nurse impaired, whether due to drug abuse or the use of other mind-altering substances, is vital to the success or failure in the ability of the staff to provide their patients with proper care. Since nurses represent the largest discipline within the healthcare infrastructure, strong leadership is vital to a healthy work environment, job satisfaction, improved patient safety outcomes, lower turnover rates, and positive outcomes for organizations, patients and healthcare providers (Curtis, de Vries, & Sheerin, 2011). The primary requisites for successful management and leadership, as depicted by Marquis & Huston (2012), are decision making, problem solving, and critical thinking, which are considered to be learned skills that improve over time and with consistent use. The overall imperative of nursing, like all healthcare practices, is to provide optimal care to patients to help cure or better their conditions and, since the ability of the impaired nurse to achieve this function degrades according to their degree of impairment, it is vital for nurse leaders and managers to address these issues. Impaired nurses pose a significant risk to the health and safety of patients and it is essential that management and leadership staff members have accurate information regarding the prevention, identification, investigation, and reporting of a nurse with a substance abuse or chemical dependency problem so that they are able to assist in the referral of a nurse with a substance abuse or chemical dependency problem for appropriate assessment and monitoring (Colorado Board of Nursing, 2003). In addition, seeking help for the impaired nurse can potentially enable the nurse to eventually return to their duties once they have completed their recovery. Each year, statewide monitoring agencies receive thousands of complaints against RNs and LPNs, and a significant number of these complaints are regarding suspected drug/alcohol/chemical dependency issues, which makes the condition of the impaired nurse a significant national problem. For this reason, the topic of managing the impaired nurse is of significant interest and is one I feel should be addressed. Since one aspect of a nurse’s duties includes administration of controlled drugs to patients, they have ready access to an inexhaustible supply of controlled substances. Although many hospitals and institutions have measures in place to prevent the misuse of these narcotics, impaired nurses are often able to circumvent these measures and gain access to drugs intended for their patients (Colorado Board of Nursing, 2003). This is referred to as ‘diversion’, which, according to the Colorado Board of Nursing, (2003, p.1) “occurs when a controlled substance or a drug having a similar effect is not used as prescribed. Drug diversion includes obtaining a controlled substance or drug having similar effects from wastage.” However, there are additional strategies that may be implemented to prevent and detect the diversion of controlled drugs, but the effectual implementation of change or new procedures requires strong management and leadership. Recognizing the indicators of impairment in staff nurses is an important part of the duties of leadership and management nurses. Physical symptoms may include tremors, jitteriness, weight loss, diaphoresis or heavy perspiration, unusual pallor, blackouts, speech irregularities, gastrointestinal upset, watery eyes, sniffling, alcohol on breath or signs of attempts to cover up the smell, and chronic clumsiness (Dunn, 2005). Impairment may also prompt emotional changes, like increased anxiety, rapid mood swings, vacillation between lethargic and hyperactive states, increased defensiveness, depression, sudden uncooperative attitudes, and difficulty focusing (Dunn, 2005). Changes in performance that may indicate impairment include unexplained absences or disappearances, frequent mistakes in routine duties, increased time spent taking breaks and charting, a preference for minimal supervision, difficulty concentrating, frequent requests for help with assignments, overreaction to criticism, abusive language and behavior, or a general deterioration from previous levels of competency and job performance (Dunn, 2005). However, the initial symptoms may be mild and may take the form of odd and disruptive behaviors, like yelling at colleagues, being verbally abusive, slamming doors, throwing objects, sending threatening e-mails, use of profane language, starting fights, pounding fists or objects on furniture, and adopting an intimidating manner towards colleagues or patients (Dunn, 2005). Since all disruptive behaviors are not the result of impairment, the nurse leader must be able to properly evaluate the situation to determine that impairment is the root cause of the disruptive behaviors. Each case must be systematically examined for an alternative solution and not rely on the unconscious processes known as heuristics, which allows problems to be solved more quickly by building upon experiences they have gained in their lives (Marquis & Huston, 2012). The heuristic approach uses trial and error methods or general rules rather than set rules, which encourages learners to discover solutions for themselves (Marquis & Huston, 2012). Leaders recognize the value of heuristics in decision making, but caution that heuristics are basically shortcuts, not fail- safe rules, and relying on heuristics is not a guaranteed method that will work all of the time (Marquis & Huston, 2012). Evidence based practice is the catalyst for innovation in nursing leadership (Curtis, de Vries, & Sheerin, 2011), which emphasizes nurses assuming responsibility for influencing and improving the practice environment (Hyrkas & Harvey, 2010). One model of change theory that can be applied to the management of the impaired nurse if Kurt Lewin’s change theory, which references social action as a feature characteristic of change (Snyder, 2009). Change theories are frequently used in nursing to effect planned changes, which involves recognizing a problem and creating a plan to address it and the nurse manager’s role as a leader in facilitating this change is vital to its success (Shanley, 2007). Lewin’s theory involves three stages, which are unfreezing, change, and refreezing (Kritsonis, 2005). The first stage begins the process of creating the awareness that change is needed and acceptance of the proposed method to implement the change, the second stage is the implementation process, and the third stage involves the process of making the implemented changes a permanent part of the institutional regime (Kritsonis, 2005). This theory is based on the analysis of the driving and restraining forces to determine how best the driving forces can be used to facilitate the changes proposed and how to achieve equilibrium despite the hindrances and opposition of the restraining forces (Kritsonis, 2005). The planned change model proposed by Lewin involves the orchestrated processes of unfreezing the present situation, moving to a new situation and refreezing in the new situation, which relies on the leadership and management teams’ ability to control the outcomes of the proposed changes (Shanley, 2007). This linear model indicated a predetermined number of steps that the must be enacted in order to realize the change and does not compensate for the erratic patterns that may develop as fallout caused by the changes, which are elements of the oppositional or restraining forces. Since all forms of learning and change are initiated by some type of dissatisfaction or frustration, Lewin's theory proposes behavioral change as "a dynamic balance of forces working in opposing directions or hopes” (Kritsonis, 2005). While drug and alcohol abuse is found in every healthcare discipline, it is an especially delicate problem for nurses, and a staff member practicing in an impaired state can expose the organization to the substantial costs associated with absenteeism, poor performance, regulatory action, and allegations of negligence and poor governance (Dunn, 2005). There are numerous potential solutions to managing the impaired nurse and avoiding divergence. One primary solution is to construct and implement a plan for determining the signs and stages of impairment. This would entail equivocally defining the blatant and subtle symptoms that signal impairment and providing educational forums that will teach colleagues how to recognize these traits in their team members. Providing supportive recommendations for treatment would also be beneficial, as this would provide a solution and referential material for managers and nursing leaders to provide to staff members that are impaired. Nurse leaders should be educated as well as all other managerial staff and those supported by nurses. Another precautionary measure to prevent impairment should be implemented in the form of administration aimed towards the prevention of medication divergence. Primarily, the majority of health care facilities report drug diversion as a result of an incident, such as a patient reports that they did not receive their pain medication or a nurse is found in a bathroom unconscious from an overdose of narcotics (Colorado Board of Nursing, 2003). Although regular monitoring of medication records can drastically reduce or prevent these incidents, there are also additional measures that should be taken to monitor drug administration. These include monitoring how drugs are administered, wasted and documented and noticing occurrences like nurses that sign out doses of medications that are not documented in the medication administration record and/or nurse’s notes, nurse that medicate another nurse’s patient, nurses that say s/he was “too busy” or “forgot” to obtain a witness to waste the controlled substance, nurses that sign out larger doses of controlled substances when the ordered dose is available, then sign that the remaining medication was wasted, nurses that say s/he gave her/his controlled substance access code to another nurse, and numerous other tell-tale signs that the nurse may be diverging medications (Colorado Board of Nursing, 2003). Since Fentanyl is one of the most frequently diverted drugs because 28%-84% of the medication remains in a fentanyl patch after 72 hours, nurses often divert patches by removing the patch from the patient and keeping it, removing a new patch and keeping it and replacing the used patch on another part of the patient’s body, removing the medication from the patch with a syringe, removing patches from sharps containers, and removing fentanyl from drug stock (Colorado Board of Nursing, 2003). Significant measures must be undertaken to ensure that medications are applied to the correct patients in the correct dosages and not diverted by impaired nurses. These measures include conducting regular inspections of controlled substance packaging and appearance for drug substitution (Colorado Board of Nursing, 2003). Another measure would be to have a pharmacist inspect any medications returned to the facility by a nurse, for instance, if the nurse claims that they took the missing controlled substance(s) home by mistake and a refractometer should be purchased for drug identification (Colorado Board of Nursing, 2003). One primary preventative measure is to conduct pre-employment screening, like drug screening, criminal background checks, and licensure verifications (Colorado Board of Nursing, 2003). Establishing and enforcing routines for the safe disposal of controlled substances, accepting deliveries of controlled substances, and fitness for duty policies and procedures that support timely and appropriate intervention when impairment is suspected (Colorado Board of Nursing, 2003) can all coincide to help prevent impairment and provide assistance to nurses that are impaired immediately, before adverse occurrences can jeopardize patients or the facility. Additional strategies for managing the impaired nurse include educating all managerial personnel on common behaviors displayed by nurses with chemical dependency problems and ensuring that supervisors know when they can require alcohol and drug testing (Colorado Board of Nursing, 2003). It is also imperative that nurse leaders and managers are aware of the reporting requirements to the Board of Nursing and other agencies (Colorado Board of Nursing, 2003). All current and potential employees should be informed of the company’s prevention plan, which should be reviewed on a regular basis (Colorado Board of Nursing, 2003). While there is no strategy impervious to the possibility of the development of an impaired nurse, since substances can be obtained and used outside of the facility, these methods illustrated can help the leadership nurse detect and manage the occurrence of an impaired nurse on their staff. However, the most significant of these methods, in my opinion, is the implementation of a comprehensive strategy to detect the impaired nurse. Making sure leadership staff is able to detect the impaired nurse is one of the best ways to effectually prevent the dangers and complications that can arise from the lackluster performance of an impaired nurse. This method requires frequent meetings and analysis of the performance of the nursing staff, which will help the staff stay in constant communication. This method also keeps the nurse leaders aware of the signs and symptoms of substance abuse so problems can be detected early and resources provided for the impaired nurse to get treatment. Early detection of such problems gives a stronger likelihood that treatment will lead to permanent recovery and the nurse will be bale to return to work. Recognition of the symptoms of impairment will also help ensure the prevention of harm to patients due to the dysfunction of the nurse. Aspects of this method that may be detrimental to the continuity of the function of the institution include the reliance of the determination of impairment on behaviors that can easily be misconstrued. In addition, some nurses may feel that the frequent meetings and evaluations this method entails consist of micromanagement or affirmations of their inability to perform their duties competently. Another con could arise in that intervention procedures may be seen as an invasion of the impaired nurse’s right to privacy. Overall, there are a myriad of pros and cons that can be attributed to this method of managing the impaired nurse and no method is without its share of positive and negative aspects. Consequently, the most important aspect in managing the impaired nurse is the nurse leader. Organizational change and the role of the manager as the primary change agent are imperative to the successful implementation of organizational and structural change. The need to identify restraining and driving forces within an organization are vital to the successful implementation of Lewin’s change theory, whereas a driving force could be pressure from a supervisor, while economics could be a restraining force (Stephenson, 2001). Effectual nursing leadership divides the behaviors and practices of nursing leaders categorically by their traits and characteristics, the impact of the healthcare context and practice settings, and educational participation of nursing leaders. “Leadership in nurses can be developed through educational activities, modeling and practicing leadership”, with the core competencies and components being: critical thinking, communication, assessment, nursing technology and resource management, health promotion, risk reduction and disease prevention, illness and disease management, information and health care technologies, ethics, human diversity, global health care, healthcare systems and policy, provider and manager of care, designer, manager and coordinator of care, and membership of a profession (Curtis, de Vries, & Sheerin, 2011) Change can occur in many shapes and sizes, with various levels of intensity and urgency. These variations may require frequent alterations and adjustments to the models intended to instigate the changes. Since there is no perfect or comprehensive model for implementing change, there is no sure-fire construct for managing the impaired nurse. The method applied by the leadership nurse will be based on the institutional norms and requirements as much as the leadership nurse’s understanding of the issues relevant to various factors, such as their underlying worldview and their explicit or implicit theoretical understanding of change, the management literature on change management, the unchallenged power of management to initiate and direct change management programs, economic reasons for justifying change programs, organizational, personal or social reasons, and political behavior is always part of change management but is often not openly acknowledged. References Colorado Board of Nursing. (2003). Resource Manual: The Impaired Nurse. Retrieved from www.dora.state.co.us/nursing. Curtis, E.A., de Vries, J., & Sheerin, F.K. (2011). Developing Leadership in Nursing: Exploring Core Factors. British Journal of Nursing, 20(5), pp.306-309. Dunn, D. (2005). Substance Abuse Among Nurses: Defining the Issue. AORN Journal, 82(4), pp.572-596. Hyrkas, K. & Harvey, K. (2010). Leading Innovation and ChangeJournal of Nursing Management, January, 18(1), p1-3. Retrieved from EBSCOHOST doi: 10.1111/j.1365-2834.2010.01069.x Kritsonis A. (2005). Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity, 8(1). Marquis, B.L. & Huston, C.J. (2012). Leadership Roles and Management Functions in Nursing: Theory and Application, 7th ed. Lippincott Williams and Wilkins, Wolters-Kluwer Health Shanley, C. (2007). Management of Change for Nurses: Lessons from the Discipline of Organizational Studies. Journal of Nursing Management, July, 15(5), pp.538-546. Retrieved from EBSCOHOST doi: 10.1111/j.1365-2834.2007.00722.x Snyder, M. (2009). In the Footsteps of Kurt Lewin: Practical Theorizing, Action Research, and the Psychology of Social Action. Journal of Social Issues, March, 65(1), pp.225-245. Retrieved from EBSCOHOST doi: 10.1111/j.1540-4560.2008.01597.x Stephenson, C. (2001). Management Function Analysis: Learning From the Expert. Nursing Forum, July-September, 36(3), pp.9-11. Read More