Two clinicians share their stories
[Editor’s Note: Two clinicians who have overcome a substance abuse problem agreed to share their personal testimony with ED Management. We have agreed not to publish their names in order to protect their privacy.]
Clinicians with substance abuse problems often say they don’t get help until they’re truly desperate.
"My big fear was that the board of pharmacy would seek legal action," says a former emergency nurse from a small urban hospital who suffered a relapse after being drug-free for seven years. "I relapsed due to professional and personal pressures. I knew I was in trouble and couldn’t control or stop my usage, so I called and got myself into an outpatient treatment program."
Shortly afterward, the nurse was confronted by the ED’s nurse manager, who had noticed a discrepancy in drug withdrawals. "I pretty much resigned myself to the fact I’d lose my license, and my biggest fear was that the board of pharmacy would seek legal action and arrest me," says the nurse.
When the nurse admitted he’d been abusing opiates again, the supervisor contacted the state board of nursing, and the nurse was immediately put on leave and referred to the state’s alternative program, a process that enabled him to retain his license after undergoing a six-week intensive outpatient treatment program. After the program was completed, the nurse went back to work. Monthly random urinalysis tests are done by the nurse’s employer, and he was moved to an ICU unit for a year because it isn’t possible to work in the ED with a narcotics restriction.
"I was totally unaware there was such a program, I thought for sure I’d lose my license and job, and there goes the house," he says. "When I went on medical leave, my employer told me they’d support me and I would have a job when I got back, and I was so relieved. I don’t know that going before the board of nursing and being punished for my actions by having my license permanently removed would have gotten me anywhere. Being medical professionals, we need to be setting the example as far as getting people into treatment and supporting them in their recovery."
The fact that the nurse’s confidentiality was respected made things a lot easier he says. "My supervisor left it up to me how much I wanted to disclose," he says. "Before I left, there was a unit meeting and he just told everyone I was going on leave, and it was uncertain when I’d be returning to work. Otherwise, it would have fed the rumor mill, and made returning back and meeting face-to-face with my peers a lot more difficult."
However, after he returned to work, honesty was an essential step in his recovery, he says. "I let my coworkers know about my problem," he recalls. "I expected the worst. There was some stunned disbelief, but everyone just really pulled together and, overall, were very supportive. People asked me what they could do to help."
Although reactions were mixed, admitting the problem publicly was beneficial, he says. "Some of the physicians I worked with have been openly supportive, and others sort of backed off, but just the act of going in there and being open and honest [and] getting it off my chest was a big relief.".
An emergency physician who became addicted to narcotics was placed on leave for 90 days of inpatient treatment and says his ED manager’s consistent support was instrumental in his recovery. "He didn’t blame me or judge me, and that really set the tone for everybody else in the department," emphasizes the physician. "I was amazed that people were genuinely, honestly, interested in my welfare. All people really wanted to know was if I was OK."
Having a matter-of-fact attitude about his problem helped speed his recovery. "When I came back to work, I felt it was really my obligation to share what happened to me with everybody, particularly with the residents," says the physician. "Once I did that, I was able to move on."
Consider liability issues when managing drug-impaired staff
In addition to helping impaired clinicians get treatment, ED managers must also be concerned with the liability risks they present, says Nayda Poblete, RN, BSN, COHN-S, ARM, a consultant in occupational health, safety and worker’s compensation in Orange County, CA who has worked extensively with hospitals. "In the ED, any one mistake could be life-threatening or fatal, and all a hospital needs is one publicized case [where the] judgment and concentration of an impaired staff member is at fault," says Poblete.
Drug screening can be a valuable risk-control measure , but they must be carefully planned and implemented. "It’s important to seek legal counsel to ensure your ED’s policy is well-written, fair, and consistent," says Poblete. Employees should be given a copy of the policy and informed about its purpose, she recommends.
The written policy facilitates testing for probable cause. "If a supervisor notices odd behavior and believes someone is under the influence, they can follow policy and test them at that time, but you can’t use this policy to retaliate against one employee," says Poblete.
In most cases, the only person who has a right to know the results of the drug screening test is the employee. "The only time the results can be shared with the supervisor is when they are relevant to job performance," says Poblete. "If the results are shared, the supervisor should know to keep this confidential. If the supervisor shares the result with other individuals, the employer can be held liable for violating confidentiality," she explains.
When suspicion of drug use arises, searching employees is acceptable if it’s part of the written policy. "In some cases, it’s reasonable to search lockers, desks, or any other hiding place located on company property," says Poblete. "You also have the right to do physical searches of the person, but do that with great care, because you may be subject to assault and battery charges, and impaired clinicians frequently become belligerent anyway when confronted, which can be very dangerous." It is best to have them voluntarily empty pockets or open lockers whenever possible.
ED managers should amass ample documentation to support their suspicions when confronting staff. "The number one thing to document is job performance," says Poblete. "The fact that somebody has bloodshot eyes isn’t enough to accuse them. You need enough reasonable symptoms and evidence before you say something."
When a problem is suspected, it’s a good idea to speak to the clinician directly and always conduct the meeting with either a human resources representative or another management person in attendance, says Poblete. "Don’t tie it to a drug problem right away, you can start by saying, We have noticed a lot of absences in the last month,’" she advises. "If the only reason you suspect them is an absentee problem, explore the reason first, as is appropriate, and offer the hospital’s employee assistance program. Somebody may say they’ve been sick or have child-care problems, so, at that point, address the problem indirectly but direct them to the right resource."
Exercise caution until suspicions are confirmed, advises Poblete. "You need to look at everything, a nurse may be wobbling, not keeping eye contact, and have clammy skin, but keep in mind that a lot of these symptoms can be somebody using a prescribed drug, so you can’t jump to conclusions."
Still, err on the side of protecting the patient. "For all you know, the employee may suffer from another medical problem, but if you determine she’s not fit for duty at that very moment, pull her out right away, because you have an obligation to the patient’s safety," says Poblete. "Don’t say anything inflammatory or say, We think you’re under the influence.’ Just be descriptive of what you have noticed."
The most common response is outright denial. "If they’re adamant that they’re not taking anything, just tell them, I really feel you shouldn’t go back out there, and I’d like to subject you to testing,’ but you need to sign a consent form," says Poblete. "If the employee says, Absolutely not,’ then you have a challenge on your hands. Tell them, If you so strongly believe we are wrong, the drug screening should prove that..’" If the employee still refuses, he or she should be placed on administrative suspension until the next appropriate step can be taken, she recommends.
As soon as the employee is out of your office, a follow-up investigation should be done. That should include speaking to individuals who worked with the person under suspicion. "But, be very selective in who you talk to. Start with the person who worked the closest with them, but don’t ask leading questions like, Did everyone notice Mary looks drunk today?’ because that can get you in a lot of trouble," warns Poblete. "If you revealed more info than you needed to, the employee could claim you caused them mental harm by making false accusations."
If it’s determined there is a problem, you need to decide whether to terminate the employee or provide treatment. "Consider that, in most cases, the cost of a six- to eight-week rehabilitation program is almost equal to the money invested in hiring and training a new employee," says Poblete. "And, you’re not only helping the individual, but you have the same person back on staff. Again, you need to consider the fairness of your policy. Why would you rehab a doctor but not a clerk?"
There is also a danger of lawsuits filed by patients who have been treated by an impaired clinician. "But, realize that there has to be an injury to the patient, they can’t just sue because they think the nurse is high on drugs," says Poblete. "Still, whether the patient sues or not, if they notice their clinician is impaired, the mere appearance to the patient that your facility is the kind of place that would tolerate that can do substantial damage to your public relations."
Including the words "this is a drug-free workplace" in advertising and human resources can act as a deterrent to employees with substance abuse problems, says Poblete. "Some people with problems will drop that application form as soon as they read that," she notes. "When another hospital in the community has a policy and you don’t, guess where the ones with the problems end up?"
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